Revenue Cycle Management

Job Description

Job Summary:

The Revenue Cycle Management Associate is responsible for various reimbursement functions, including but not limited to pharmacy clearance, accurate and timely claim submission, claim status, collection activity, payment posting, and/or refunds, wholesale credentialing, order processing, invoice processing, collection activity, payment posting and/or refunds and manufacturer services (“HUB”) intake, clearance, and triage of prescriptions. The below is intended to describe the general content of and requirements for the performance of this job and is not to be construed as an exhaustive statement of essential functions, responsibilities, or requirements.

Primary Duties and Responsibilities

Work with government and commercial payers to identify (i) drug coverage for AnovoRx’s prescription drugs; (ii) patient eligibility for coverage; (iii) prior authorization and appeal requirements; (iv) primary and secondary coverages; and (v) plan limitations (i.e., maximum quantity per order, refill too-soon, timely filing).

Must know acceptable reimbursement ranges for each AnovoRx drug and be able to convert reimbursement rates expressed in WAC and pre-settlement AWP to post-settlement AWP equivalency.

Must know and be able to apply the Company’s policy of restrictions on and acceptable Able to perform a preliminary review of payer contracts (prior to sending to AnovoRx Counsel for review) to identify (i) type of plan; (ii) acceptability of reimbursement rate; (iii) whether an exhibit or addendum is tied to an underlying contract and whether that contract is present; (iv) whether all portions of the contract (inclusive of schedules, exhibits, pricing and addenda) are present; and (v) whether effective date is expressed and acceptable.

Know or be able to research claim filing requirements for each payer plan and apply knowledge claims processing accurately and timely.

Identify past due and aging accounts and perform collection calls in accordance with AnovoRx policy. Ensures proper entry of customer information in the proper database (distinguishing wholesale customers from patients).

Timely notify AnovoRx management of problem accounts, e.g., overpayments, underpayments, or no payments at all.

Identify claim denials and secondary billing requirements, determine the reason for claim denials, and follow-up appropriately and within the applicable appeal and secondary filing periods.

Identify the need for a letter of agreement, determine if a product LOA or a patient –specific LOA is appropriate, negotiate with the payer for acceptance of the letter of agreement and a reimbursement rate within the AnovoRx acceptable range, and pursue full execution of the LOA. Ensure appropriate reimbursement is received. Obtain supervisor approval for any LOAs that contain exceptions to AnovoRx’s guidelines.

Effectively complete reports and special projects as requested by AnovoRx management.

Ensure confidentiality of all patient accounts by following HIPAA guidelines and adhering to all company HIPAA policies and procedures and completing all company required HIPAA training in a timely manner.

Post any denials received from insurance payers and work with the payer to rebill.

Knowledgeable or able to research appeal process for applicable payer, implement and follow the appeal process, communicate the appeal to the prescriber and patient, and pursue an appropriate payment.

Post cash receipts and adjustment requests and explanations timely as identified.

Submit patient pay statements on a weekly or monthly basis and collect outstanding patient balances.

Knowledgeable of available financial assistance programs for each AnovoRx drug, able to research and apply to and communicate to each subject patient, the qualification criteria for each such program, and able to ascertain if the subject patient has gathered all evidence required to meet the qualification.

Possess a general understanding of manufacturer Business Rules.

Credential new wholesale customers by verifying contract paperwork, pharmacy license, 340B or FFS status (if applicable), and any other VAWD mandated items.

Ensure new wholesale customers receive notification of account set up and account number along with the appropriate purchasing forms.

Process all wholesale orders (via phone, fax, email) and verifies pharmacy license and 340B/FFS prior to confirming order.

Create wholesale invoices and sends to customer, work any collection activities if account becomes past due and posts all payments.

Follow all applicable AnovoRx wholesale and VAWD policies and procedures.

Timely process all HUB referrals and triage to the appropriate pharmacy for dispensing.

Ensure all reimbursement, wholesale, and HUB phone lines are answered in a reasonable amount of time during business hours, any voicemails are resolved timely and provide excellent customer service.

Knowledgeable of and adheres to all applicable laws and AnovoRx polices.

Properly store and maintain paper and electronic records and obtain fully executed contracts.

Take inbound and outbound calls adhering to call quality guidelines.

Regular and reliable attendance expected.

Other work-related duties as assigned by supervisor/manager.

Minimum Knowledge, Abilities, and Skills Required

Must have a high school diploma or equivalent.

At least two years’ experience in Medicare and Medicaid billing and collections.

Must have excellent computer skills; proficient at Microsoft Office Suite primarily Word, PowerPoint, Excel.

Must be highly motivated, people friendly, organized and detail oriented.

Able to work independently as well as in teams.

Must have history evidencing reliability and consistency in timeliness, attendance, and quality of work.

Must present yourself professionally on the phone and in person.

Must articulate thoughts well and communicate them clearly, both verbally and in writing.

This description is intended to be only a general outline of major activities. It is expected that the employee performs these and any other activities which may be assigned, or which may occur in the normal course of work. This description is not a contract or guarantee of employment. AnovoRx is an Equal Opportunity Employer.