**Job Description** Provide analysis and demonstrate understanding of pharmacy revenue cycle management to optimize the payment cycle for retail and specialty pharmacy claims. Ensure maintenance and understanding of the overall workflow of pharmacy accounts. Review payments for accuracy, ensure collection according to contracts, understand and follow-up with insurance companies to leverage the revenue process. Utilize preferred collection procedures to obtain third party payments and ensure compliance with payer contracts. Ensure accuracy of secondary billing processes and related vendor data feeds into systems as required. Advocate on behalf of MSHS to ensure the most efficient processes regarding claim resolution. Evaluate denials, short-pays and rejections. Provide proactive and ongoing follow-up and problem solving with insurance companies and pharmacy sites to identify trends, communicate proactively, and ensure accuracy in the process. Contribute to scalable process improvement to advance external revenue from the national strategy platform with pharmacy business office services. **Qualifications** + Bachelor’s in business, healthcare or related field or equivalent combination of education and related experience required. + Three years healthcare reimbursement analysis, collection experience, revenue cycle process knowledge experience and/or pharmacy insurance experience required. + Five years pharmacy reimbursement analysis and collection experience with Medicare, Medicaid, Pharmacy Benefit Manager and Commercial Health Plan payer experience. Pharmacy dispensing knowledge and/or experience preferred. + Registered Technician preferred. , 600 - HSO Pharmacy - MSH, Mount Sinai Hospital **Responsibilities** Understand the overall workflow to proactively solve problems, provide analysis and evaluate trends in the revenue cycle. • Demonstrates analytical skills including the ability to reconcile payer remittances. • Understands the payer denials and impact on MSHS revenue cycle and overall margins. • Displays initiative to resolve 835 remittance issues including but not limited to; unapplied cash, claim exceptions and partial pays. • Evaluates contracts, analyzes payments and proactively problem solves to optimize the pharmacy claim payment cycle. • Provides claims resolution to ensure accuracy in the process. • Proactively communicates with pharmacy site staff, revenue integrity operations staff, and insurance companies (both pharmacy benefit managers and health plans) to escalate and resolve claims payment discrepancies. • Analyzes existing reimbursement arrangements/networks and reimbursement and operational issues with claims systems and their subsequent impact on financial results. Understand contracts to achieve results and department metrics; including but not limited to: • Payer Days Service Outstanding (DSO) equals or exceeds department goals • Open Accounts Receivable % aged greater than 60 days meets or exceeds department goals • Ensures timely submission of secondary payer billing which meets or exceeds department goals. • Ensures applied cash targets are met for assigned payers. Review payment for accuracy, ensure collection according to contracts, understand and follow-up with insurance payers (both pharmacy benefit managers and health plans) to leverage the pharmacy revenue cycle process. • Utilizes preferred collection procedures to obtain third party payments and ensures compliance with MSHS payer contracts. • Ensures accuracy of secondary billing processes and related vendor data feeds into systems as required. • Understands regulatory, HMO, PPO, Federal, State and other third party payer requirements needed to prepare and or process claims. Ensure optimal revenue cycle performance through evaluation, analysis and problem solving. • Uses data for projections as part of contractual analysis. • Completes detailed financial impact analysis of provider rate. • Produces reports for payment variances, rejected, denied and partial pay claims • Reviews aging reports that have reached certain aged categories (30, 60, 90 days, etc) • Generates manual and on-line billing for resubmission for third party payer’s outstanding balances. • Reviews payment process for accuracy; provides necessary follow-up. • Communicates and resolves reimbursement issues to coordinate payer/provider relations between payers and MSHS. • Identifies and communicates trends to PBO leadership to improve overall pharmacy revenue cycle performance • Provides analysis to stakeholders with explanations of reimbursement findings from assigned providers utilizing Excel and displays initiative to assist in identifying potential compliance issues to MSHS staff and makes recommendations to Finance management for resolution. • Constantly analyzes operations, and attempts to improve processes in order to provide better customer service and improve the pharmacy revenue cycle (including minimizing controllable loss categories, i.e. Timely Filing) Attend periodic meetings with payer representatives to discuss discrepancies and assist in developing action plan for correction. Contribute to scalable process improvement to advance external revenue from the national strategy platform with pharmacy business office services. • Provides retail, specialty, compounding and long-term care pharmacy revenue cycle insights to venture partner teams and PBO vendors to assist with product/service improvement. • Collaborates with PBO leadership team to assist in the development of new process capabilities to improve efficiency, scalability and margin for MSHS. • Uses problem solving and critical thinking to evaluate to identify, define, analyze and resolve work problems through investigation of alternative ideas and approaches **About Us** **Strength through Unity and Inclusion** The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. **About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. **Equal Opportunity Employer** The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $79720 - $119580 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.