Company Overview
Lyceum Health has deep roots in the digital health marketplace to improve care for patients and their care teams. We are passionate in solving real life problems through our creativity and our culture of innovation and our goal is to create best-in-class digital products that users can trust and stand up to the quality standards. We are looking for talented and driven individuals to join our fast-growing team.
Summary
We are seeking an experienced Pharmacy Billing and Collection Manager to lead and manage the billing operations for our specialty pharmacy. This role requires deep expertise in both pharmacy and medical billing, with a strong understanding of reimbursement processes across commercial and government payers. The ideal candidate must have at least five (5) years of experience in pharmacy billing, medical claims processing, and revenue cycle management, be comfortable with travel, and possess a proven track record of building and managing high-performing teams. This role requires a strong understanding of CareTend software.
Responsibilities
Billing Operations & Revenue Cycle Management:
- Oversee and manage all aspects of pharmacy and medical billing, ensuring compliance with payer policies and regulatory guidelines.
- Develop and implement best practices for billing workflows to maximize reimbursement and reduce claim denials.
- Lead the team in handling adjudications, rejections, denials, and appeals across multiple payer types (commercial, Medicare, Medicaid).
- Ensure proper coding, documentation, and claim submission in alignment with payer requirements.
- Monitor accounts receivable (A/R), collections, and cash flow, providing reports and recommendations for improvement.
Technology & Systems Management:
- Ensure efficient use of CareTend or current pharmacy system software for claims processing, reporting, and revenue tracking.
- Collaborate with IT and vendors to optimize billing system capabilities and troubleshoot issues.
Compliance & Regulatory Oversight:
- Ensure compliance with HIPAA, Medicare, Medicaid, and PBM regulations related to pharmacy and medical billing.
- Stay updated on CMS, payer policies, and industry changes to ensure billing practices remain compliant and up to date.
Leadership & Team Development:
- Lead, mentor, and train the billing team to enhance performance and efficiency.
- Establish key performance indicators (KPIs) and monitor team productivity.
- Utilize CareTend or current pharmacy system to streamline billing workflows and reporting.
- Work cross-functionally with finance, operations, and payer relations teams to align billing practices with business goals.
- Develop and implement standard operating procedures (SOPs) to improve efficiency.
- Conduct regular performance evaluations and provide feedback to team members.
- Work cross-functionally with finance, operations, and compliance teams to ensure seamless billing operations.
Scope of Work:
- Developing and overseeing a billing and reimbursement team.
- Process and submit pharmacy and medical claims accurately and efficiently.
- Work directly with payers to resolve claim denials, rejections, and underpayments for specialty medications.
- Verify and interpret insurance benefits, prior authorizations, and coverage limitations for specialty drugs.
- Monitor and follow up on accounts receivable to ensure timely reimbursement.
- Reconcile payments and adjustments to patient and insurance accounts.
- Maintain compliance with Medicare, Medicaid, and commercial payer guidelines, as well as specialty pharmacy accreditation requirements (URAC, ACHC, etc.).
- Work closely with internal departments, including intake, sales, and clinical teams, to streamline the billing and reimbursement process.
- Utilize CareTend or the current pharmacy system for billing processes, claims management, and documentation.
- Identify trends in denials and provide feedback for process improvement.
- Assist with audits, appeals, and documentation requests from payers.
- Drive projects forward via daily status reports and check-ins with key stakeholders
- Other duties as assigned
Job Type: Full-time
Pay: $80,000.00 - $120,000.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Experience:
- specialty pharmacy or home infusion billing: 5 years (Preferred)
Ability to Commute:
- Dublin, OH 43016 (Required)
Ability to Relocate:
- Dublin, OH 43016: Relocate before starting work (Preferred)
Work Location: Hybrid remote in Dublin, OH 43016
