Pharmacy Billing Specialist

Job Overview:

The Billing Specialist is responsible for the timely and accurate preparation, review, and submission of medical and pharmacy claims for assigned clients across Ambulatory Infusion Centers (AIC), Specialty Pharmacy (SP), and Home Infusion services. This role ensures claims are billed in accordance with payer requirements, coding guidelines, contractual obligations, and client-specific workflows to maximize reimbursement and reduce denials.

The Billing Specialist works closely with intake, prior authorization, cash posting, accounts receivable, clinical, pharmacy, and client teams to ensure accurate claim generation and successful reimbursement outcomes.

Responsibilities:

Your key responsibilities will include:

• Claim Preparation & Submission
• • Review patient accounts for billing readiness.
  • Verify all required documentation, authorizations, and charges are present prior to claim submission.
  • Prepare and submit professional, facility, infusion, and pharmacy claims to payers.
  • Ensure claims are submitted within payer filing deadlines.
  • Review claims for completeness and accuracy before submission.
  • Monitor claim transmission reports and resolve claim rejections promptly.
• Infusion Billing
• • Bill infusion therapies in accordance with payer-specific guidelines.
  • Review and validate HCPCS, J-Codes, CPT codes, ICD-10 diagnosis codes, modifiers, units, and place of service codes.
  • Ensure accurate billing of drug administration services, hydration, injections, and infusion procedures.
  • Verify infusion documentation supports billed services.
  • Monitor payer-specific infusion reimbursement requirements.
• Specialty Pharmacy Billing
• • Submit specialty pharmacy claims through applicable pharmacy and medical benefit channels.
  • Review claim adjudication responses and identify claim issues.
  • Resolve claim rejections and payer edits.
  • Coordinate with pharmacy teams regarding prescription, dispensing, and reimbursement requirements.
  • Support coordination of benefits activities.
• Home Infusion Billing
• • Review home infusion services for billing accuracy.
  • Ensure nursing, drug, supply, and administration services are billed appropriately.
  • Verify documentation meets payer requirements.
  • Submit home infusion claims in accordance with payer and regulatory guidelines.
• Claim Edit & Rejection Management
• • Monitor clearinghouse and payer claim edits.
  • Research and correct rejected claims.
  • Resubmit corrected claims within established turnaround times.
  • Identify recurring billing issues and recommend process improvements.
  • Collaborate with intake and authorization teams to prevent future billing delays.
• Authorization & Documentation Review
• • Verify prior authorizations are obtained and documented appropriately.
  • Confirm authorization requirements align with billed services.
  • Ensure all required clinical documentation supports claim submission.
  • Communicate missing information to appropriate departments for resolution.
• Revenue Integrity
• • Review charges for accuracy and completeness.
  • Identify missing charges or billing opportunities.
  • Ensure compliance with payer contracts and reimbursement policies.
  • Assist in maintaining billing accuracy standards across assigned clients.
  • Escalate reimbursement concerns to management.
• Client & Team Collaboration
• • Work closely with RCM Managers and client representatives to resolve billing issues.
  • Collaborate with intake, prior authorization, cash posting, and AR teams.
  • Participate in client meetings when requested.
  • Assist with special projects and process improvement initiatives.
• Compliance & Quality Assurance
• • Maintain compliance with HIPAA and applicable billing regulations.
  • Follow Medicare, Medicaid, and commercial payer billing requirements.
  • Participate in quality assurance audits and training.
  • Maintain detailed documentation of billing activities.
  • Adhere to company policies and standard operating procedures.

Qualifications:

• High School Diploma or GED required.
• Minimum 1 year of healthcare billing experience required.
• Minimum of 1 year CareTend experience required.
• Strong CareTend knowledge with responsibility for claim validation, coding, authorization review, claim submission, and resolving rejections/rebills
• Experience in infusion services, specialty pharmacy, physician billing, hospital outpatient billing, or home infusion preferred.
• Experience with Medicare, Medicaid, and commercial insurance billing preferred.
• Experience with infusion-specific reimbursement methodologies preferred.
• Strong understanding of medical billing and reimbursement processes.
• Knowledge of HCPCS, J-Codes, CPT, ICD-10, modifiers, and payer billing requirements.
• Understanding of infusion drug reimbursement and administration billing.
• Familiarity with specialty pharmacy billing and adjudication processes.
• Knowledge of claim submission, claim edits, and rejection management.
• Strong attention to detail and accuracy.
• Excellent organizational and time management skills.
• Proficiency with EMR, practice management, and billing software systems.
• Intermediate Microsoft Excel skills.

Education:
High school diploma or GED required.

Job Benefits:
Health, Dental, Vision, Life, 401k, Paid Time Off.

Location:
Remote with limited travel to client locations, internal business meetings, and other locations as needed.