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Quality & Organizational Excellence Specialist - Pharmacy Revenue Integrity Program

This job posting is no longer active.

Job ID: 29849
Location: Morrisville, NC
Facility/Division: Shared Services
Status: Full Time
Shift: Day Job

Did you know UNC Health has Ranked #2 Most Trusted Healthcare Brand in the U.S.? The UNC Health brand was ranked as the #4 healthcare brand in the United States overall and the #2 most trusted healthcare brand, just after Johns Hopkins and before Mass General. Join our One-Great-Team!

Job Description


Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

The Pharmacy Denials Specialist will join the Pharmacy Revenue Integrity (PRI) team, which includes Denials Specialists, a Reimbursement Analyst, a Charge Integrity Analyst, and clinical pharmacists. The PRI team works with the Pharmacy Medication Assistance Program (MAP) team, the Epic Willow team, Pharmacy Analytics, the Pharmacy Business Office, and the various pharmacy clinical and operational area teams, in addition to developing and sustaining communication channels with the Revenue Cycle, Patient Financial Services, Hospital Billing, Managed Care, and Health Information Management departments to ensure clarity, consistency and accuracy around the pharmacy charge, reimbursement and revenue cycle. 

The Denials Specialist will proactively maintain specific payer work queues related to denials, researching payer coverage policies and appeal requirements, auditing patient account histories, and submitting required documentation to payers. Best practices in pharmacy denials management will be identified and developed to ensure the department is fiscally responsible and compliant with all commercial, state and federal regulations. 

The Denials Specialist will also assist in data analyses, third party reporting, and routine auditing. The Denials Specialist will provide regular updates to executive and pharmacy leadership through area assessments and compliance improvement recommendations. A dashboard summary of payer denial work queues and recommendations will be presented to pharmacy leadership and appropriate committees.

Reporting Relationships:

The Denials Specialist will report directly to the Assistant Director of Pharmacy for the Medication Assistance Program and Pharmacy Revenue Integrity. The position is remote with on-site office space available in Morrisville, NC as needed or preferred. 

The responsibilities of the Denials Specialist include, but are not limited to, the following: 

  • Proactively maintain specific payer denial work queues, researching payer coverage policies and appeal requirements, auditing patient account histories, and submitting required documentation to payers. 
  • Act as a pharmacy denials business expert and revenue cycle liaison. 
  • Lead chart audits and conduct internal audits of claims and payment to assure that uncompensated patient revenues resulting from denials of patient service billings are minimized. 
  • Review departmental denials management procedures. Annually review procedures, and ensure updates have been added. Maintain a copy of all procedures. Perform random department audits to ensure they are following their procedures. 
  • Create and submit quarterly reports to monitor the impact of missed revenue as a result of denials. Submit recommendations and assist the department with corrective action plans. 
  • Assist with and audit end-to-end pharmacy reimbursement and revenue cycle analysis to uncover pharmacy financial discrepancies and revenue loss. Coordinate operational activities to make corrections. Perform periodic audits to ensure minimized revenue loss. Compile reports and submit findings and recommendations to department leadership. 
  • Develop and sustain routine communication channels with the billing, finance, accounting, and Health Information Management departments and clarity, consistency and accuracy around the pharmacy reimbursement and revenue cycle. 
  • Develop a performance improvement plan that will record and trend high dollar denials. 
  • Prepare financial/regulatory/quality analysis reports for departmental leadership and staff. 
  • Utilize internal and external software to identify denied and/or corrected claims for payment. 
  • Compile, analyze, and report on the financial performance of departmental operating units. 
  • Initiate, extract, and analyze data elements to identify potential performance improvement and cost savings initiatives. 
  • Participate in departmental lean quality events. 
  • Participate in departmental and hospital committees. 

Skills and Attributes: 

The Pharmacy Denials Specialist should demonstrate or be willing to learn the following skills and attributes: 

  • Hospital billing (CPT/HCPCS/Revenue Codes), CDM drugmaster maintenance (eRX), and patient accounts 
  • Demonstrated understanding of medical terminology required 
  • Knowledge of patient confidentiality and HIPAA regulations 
  • Knowledge of medical billing and collection practices 
  • Understanding of Medicare and Medical Assistance regulations as they apply to job functions 
  • Knowledge working with electronic health records (EHR/EMR) or healthcare related computer systems 
  • Excellent written and verbal skills are required as well as outstanding interpersonal skills 
  • Efficient methods for getting work done; strong ability to prioritize workload 
  • Organized; sets priorities; meets deadlines 
  • Ability to work independently 

Preferred Experience:  

  • Experience in pharmacy, pharmacy finance, insurance, insurance appeals, medication and medical terminology strongly preferred. 
  • Master’s Degree and experience in a healthcare setting or physician’s practice preferred. 
  • Ability to work in self-directed manner while interacting with patients, prescribers and all medical center faculty and staff. 
  • Ability to communicate clearly with health care team. 
  • Strong demonstrated communication skills. 
  • Experience with Windows, Excel, PowerPoint, Business Objects, or other financial/analytical software. 
  • Must be highly organized, detail-oriented, and able to manage multiple projects at a time. 

Other Information

Other information:
Education Requirements:
● Bachelor’s degree in an appropriate discipline.
Licensure/Certification Requirements:
● No licensure or certification required.
Professional Experience Requirements:
● No experience is required.
● If Associates Degree: Four (4) years of experience in quality team facilitation, project management, process improvement or quality data analysis.
Knowledge/Skills/and Abilities Requirements:
● Strong team facilitation, project management, process improvement, data analysis, quality assurance skills.

Job Details

Legal Employer: NCHEALTH

Entity: Shared Services

Organization Unit: Pharm Revenue Integrity Progrm 

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job

Location of Job: US:NC:Morrisville

Exempt From Overtime: Exempt: Yes

This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care. This is not a State employed position.
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Diversity Statement

The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.

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