The Medicare Part B Billing & Accred. Specialist serves as a subject matter expert (SME) in Medicare Part B billing and documentation requirements. This role is responsible for independently managing complex pharmacy billing activities, ensuring compliance with CMS regulations, and driving resolution of systemic issues impacting reimbursement and operational effectiveness.
The position requires strong analytical skills, professional communication with internal and external stakeholders, and the ability to operate with minimal supervision while contributing to cross-functional initiatives and process improvements.
- Serves as a Medicare Part B subject matter expert (SME), responsible for interpreting and applying CMS regulations, Local and National Coverage Determinations, and payer-specific billing and documentation requirements.
- Ensures all claims are submitted accurately and in compliance with Medicare Part B, Major Medical, and Medicaid billing guidelines.
- Maintains audit-ready documentation standards and ensures all required documentation exists, is complete, and supports billed services.
- Supports ongoing compliance with federal and state regulations, CMS guidance, and applicable pharmacy/DMEPOS accreditation standards.
- Owns the end-to-end resolution of complex, high-risk, or escalated claims, including denied or rejected claims, ensuring timely and accurate adjudication.
- Independently prioritizes and manages workload across multiple systems and platforms with minimal direction.
- Resolves billing discrepancies by coordinating with pharmacy staff, prescribers, payers, and business office teams.
- Identifies, analyzes, and trends systemic billing and documentation issues; determines root causes and drives appropriate escalation.
- Partners with leadership to recommend and implement corrective actions that improve reimbursement outcomes and reduce compliance risk.
- Contributes to process improvement initiatives, workflow optimization, and standardization of billing practices.
- Assists in developing and maintaining policies, procedures, and best practices related to Medicare Part B billing and compliance.
- Collaborates with internal departments including Revenue Cycle, Pharmacy Operations, and Business Office teams to resolve complex billing issues and improve processes.
- Engages directly with external stakeholders, including prescriber offices, payers, and other partners, requiring professional and effective communication.
- Represents the Medicare Part B billing function in cross-functional meetings, audits, and external discussions as needed.
- Ensures patient profiles accurately reflect payer information, coverage updates, and required exceptions.
- Verifies patient consent requirements and ensures compliance with documentation timelines (including periodic prescriber assessments and re-education requirements).
- Monitors documentation completeness and timeliness, proactively addressing gaps prior to billing.
- Supports internal and external audits, accreditation surveys, and regulatory inspections, including follow-up on corrective action plans.
- Meets or exceeds performance metrics established by Revenue Cycle leadership, while balancing quality and compliance expectations.
- Provides detailed billing analysis and reporting (e.g., Medicare Part B billing data by location), identifying trends and opportunities for improvement.
- Other duties as assigned.
Travel: Yes: Minimally, as required (Typically less than 10%)
Qualifications
- Education: High School / GED
- Experience: 5-8 years
Licenses and Certifications:
- Associate degree in accounting, business, or related field preferred
