Lead, Mail Order Pharmacy

Position Summary

The Mail Order Pharmacy Lead will manage an assigned book of business while providing day-to-day support, guidance, and leadership to the reimbursement team. This position works closely with the Direct Manager of Revenue Cycle to address team questions, monitor productivity and progress, provide coaching, and identify training and performance opportunities.

The ideal candidate is organized, detail-oriented, professional, and knowledgeable in insurance billing, reimbursement, collections, appeals, and denials. The successful candidate will be comfortable handling complex claims while serving as a resource and mentor to team members.

Key Responsibilities

• Manage an assigned book of business, including billing, collections, appeals, denials, and claim follow-up.
• Process Workers' Compensation and Personal Injury prescription claims.
• Review aging reports and conduct timely follow-up on unpaid, underpaid, and outstanding claims.
• Investigate claim denials, payment adjustments, notices of disallowance, and other reimbursement issues, and take appropriate action to obtain reimbursement.
• Prepare and submit appeals, reconsiderations, and disputes with the required supporting documentation.
• Review and correct claim information, including patient demographics, insurance information, diagnosis codes, and CPT codes.
• Monitor claim status and follow up with insurance carriers, adjusters, attorneys, and other applicable parties as needed.
• Serve as a resource for team members by answering questions and assisting with complex or escalated claims.
• Provide day-to-day coaching, guidance, and support to team members.
• Assist the Direct Manager of Revenue Cycle with monitoring team productivity, progress, performance, evaluations, and training needs.
• Help identify process improvements and opportunities to increase reimbursement, reduce denials, and improve overall team efficiency.
• Communicate reimbursement trends, recurring issues, concerns, and opportunities to management.
• Assist with onboarding and training new team members as needed.
• Maintain accurate and timely documentation of account activity and claim follow-up.
• Assist with special projects and other Revenue Cycle responsibilities as assigned.

Qualifications

• Minimum of 2 years of experience in medical billing, healthcare reimbursement, or related field.
• Workers' Compensation, Personal Injury, or pharmacy billing experience preferred.
• Strong knowledge of medical billing, collections, appeals, denials, EOBs, ICD-10, CPT codes, and insurance reimbursement processes.
• Previous leadership, mentoring, coaching, or team support experience preferred.

Physical Requirements

• Ability to sit and work at a computer for extended periods.
• Ability to use a computer, keyboard, mouse, telephone, and other standard office equipment.
• Ability to communicate effectively through telephone, email, and other electronic communication methods.
• Requires repetitive hand and wrist movements associated with computer and data-entry tasks.
• Ability to visually review electronic documents, spreadsheets, account information, and financial records for extended periods.