Manager - Pharmacy Revenue Cycle

General Description:

The Pharmacy Revenue Cycle Manager is responsible for ensuring optimal revenue capture for pharmaceuticals across the Health System. This position will serve as a liaison between Pharmacy, Finance, Revenue Integrity, IT, Compliance, and other departments to standardize and optimize pharmacy charging workflows, pharmacy revenue, business processes, billing, denial management, and collections. This role will work with sites, managed care, and the business office to decrease medication-related claim denials and outstanding claims. The manager will provide education to site and system stakeholders to drive optimal revenue capture and act as the system expert on medication-related compliance billing and charging topics. This position will develop policies and/or guidelines to improve revenue integrity, capture, and compliance and participate in the financial analyses of any proposed changes to determine charge and revenue implications related to the pharmacy charge description master (CDM) maintenance and then communicate findings to management and overseeing the implementation of approved recommendations to ensure appropriate revenue capture.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities, with or without an accommodation, may result in disqualification from the position.

• Develop policies, guidelines, and procedures for pharmaceutical coding, billing, quality, pricing, charging, and denial management to maximize reimbursement and compliant charging.

• Develop quality metrics and audit methodologies to drive accuracy and first-time quality for all HCPCS/CPT codes, revenue codes, billable units, multipliers, modifiers, indications, etc.

• Use analytical tools to audit and analyze pharmacy data elements to ensure accurate billing and maximal revenue capture.

• Perform quality reviews to ensure that CDM additions, inactivation's, changes and/or revisions were accurately completed in the hospitals clinical and financial systems.

• Work with Pharmacy & Therapeutics Committees, Oncology Service Lines, and Managed Care to align formularies.

• Actively research and stay current with important billing and revenue related compliance and optimization topics to guide appropriate organizational decisions.

• Participate and lead committees, work groups, process improvement efforts, and educational initiatives to improve pharmacy revenue integrity and the pharmacy billing cycle.

• Develop process flows, education, and communications to improve revenue integrity and compliance.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: Graduate of an ACPE-accredited College of Pharmacy with a Doctor of Pharmacy (PharmD) or Bachelor of Pharmacy (D.Ph.) degree required.

Experience: At least three (3) years of progressive leadership experience required.

License(s)/Certification(s)/Registration(s) Required: Licensure as a Pharmacist by the Oklahoma State Board of Pharmacy required. Applicants without an active Oklahoma Pharmacist License must obtain licensure within 90 days of hire. Preceptor certification through the Oklahoma State Board of Pharmacy required within 18 months of hire. Pharmacy Revenue Cycle Management (ASHP) or HFMA certification required within one year.

Knowledge, Skills and Abilities:

• Expert-level understanding of pharmacy revenue cycle operations, billing workflows, and reimbursement processes across retail, specialty, inpatient, and infusion pharmacy services.

• Demonstrated ability to analyze complex financial data, reconcile health system accounts, and identify systemic revenue discrepancies or leakage.

• In-depth knowledge of retail pharmacy reconciliation requirements, including PBM payments, e-vouchers, register transactions, and electronic remittance files.

• Advanced ability to investigate and resolve complex billing issues, utilizing pharmacy systems and revenue cycle reporting tools to drive process improvements.

• Mastery of Microsoft Excel and Electronic Medical Records, with the ability to leverage data for analytics, reporting, and management presentations.

• Proven ability to communicate effectively and work collaboratively across pharmacy, finance, IT, and compliance teams, as well as with external payers and PBMs.

• Strong attention to detail with a commitment to accuracy, data integrity, and organizational financial stewardship in a high-volume, deadline-driven environment.

• Previous pharmacy practice experience in operations or specialized settings like infusion and oncology, with a focus on compliance and medication-related billing standards.