Pharmacy Revenue Analytics Program Lead

The Pharmacy Revenue Analytics Program Lead, reporting to the Pharmacy Business Director and Vice President & Chief Pharmacy Officer, will define and carry out the data and process improvement strategy for maximizing Pharmacy revenue. S/he, in concert with Pharmacy Informatics, will ensure the availability and interpretation of reporting and analytics necessary for the Division to drive financial improvements. The position entails financial modeling, financial impact analysis, revenue forecasting, drug utilization analysis, markup analysis, and ad hoc reporting. The Program Lead will work directly with Pharmacy staff and leadership to ensure the quality and efficiency of all elements of charge capture. The Program Lead will oversee revenue improvement initiatives, and actively develop, interpret, review, and share data from all phases of the pharmacy revenue cycle process to identify opportunities for charge capture improvement and gross revenue optimization. Independently works with the appropriate departments and revenue leaders to resolve Pharmacy revenue management issues, analyze key data metrics, systematically review data findings, and make recommendations to improve revenue capture and reconciliation. The program Lead serves as the key leader and subject matter expert within the organization who monitors and improves Pharmacy data and revenue processes for the Division.

• Develop policies, guidelines, and procedures for pharmaceutical coding, billing, pricing, charging, and denial management to maximize reimbursement and compliant charging.

• Perform quality reviews in order to ensure that the pharmacy charge description master (PCDM) additions, inactivations, changes and/or revisions were accurately completed in the hospitals clinical and financial systems.

• Work with Pharmacy & Therapeutics Committees, Oncology Service Lines, and Managed Care to ensure formularies are aligned.

• Actively research and stay current with important billing and revenue-related compliance and optimization topics to guide appropriate organizational decisions.

• Collaborate with Finance, Revenue Integrity, Compliance, Decision Support, and other departments to standardize and optimize pharmacy charging workflows, pharmacy revenue, business processes, billing, denial management, and collections.

• Lead pharmacy charging or revenue related projects and workflow changes, document areas of risk, financial impact and workflow procedures.

• Communicate findings to management and overseeing the implementation of approved recommendations to ensure appropriate revenue capture.

• Develop process flows, education, and communications to improve revenue integrity and compliance.

• Collaborate with upper management to evaluate current as well as new program initiatives for effectiveness, feasibility, performance measurement, and cost; ensure compliance with organizational and departmental policies and procedures, and regulatory standards.

• Participate and lead committees, work groups, process improvement efforts, and educational initiatives to improve pharmacy revenue integrity and the pharmacy billing cycle.

• Act as the system expert on medication-related compliance billing and charging topics.

• Provide education to site and system stakeholders to drive optimal revenue capture.

• Work with sites, managed care, and the business office to decrease medication-related claim denials and outstanding claims.

• Serve as a liaison between Finance, Revenue Integrity, Compliance, Decision Support, Pharmacy, and other departments to standardize and optimize pharmacy charging workflows, pharmacy revenue, business processes, billing, denial management, and collections.

• Collaborate with Pharmacy Leadership to determine patient access to high cost injectable therapies and other related reimbursement options, provide assistance on 340B operational reporting as it pertains to hospital outpatient departments.

• Research and stay current with important Pharmacy billing and revenue-related compliance and optimization topics to guide appropriate organizational decisions.

• Appropriately utilize industry information (e.g. from HFMA, AAHAM, etc.) and Children's National Hospital peer resources (e.g. State Hospital Association, CHA, Vizient, etc.) to understand national and regional trends, peer hospital innovations, successes, and benchmarks related to pharmacy revenue cycle.

• Responsible for overall Pharmacy Revenue Cycle Dashboard reporting on both a weekly and monthly basis, which includes data mining and report interpretation to ensure key themes are identified, addressed, and appropriately escalated.

• Develop analytical tools to audit and analyze hospital pharmacy data elements to ensure accurate billing and maximal revenue capture.

• Analyze data on all Pharmacy Revenue KPIs.

• Monitors, tracks, and trends special scenarios impacting revenue, such as oncology patients, temporary patients, medication waste, interdepartment chargebacks, etc.

• Participate in the financial analyses of any proposed changes to determine charge and revenue implications related to the PCDM maintenance.

• Develop quality metrics and audit methodologies to drive accuracy and first-time quality for all HCPCS/CPT codes, revenue codes, billable units, multipliers, modifiers, indications, etc.

• Provide strategic support of AR Strategy as it relates to items such as reporting and identify focus areas for improvement.

• Routinely identify enhancements to reports and/or tools to support leading practice processes and facilitate continuing Pharmacy Revenue Cycle improvement; provide content expertise in the development, implementation, revision and management of data systems that support the Pharmacy Revenue Cycle.

• Identify revenue improvement opportunities through analysis of data and review of current processes.

• Ensure ad hoc report requests received from other departments in the organization are managed timely and accurately.

• Provide recommendations to reporting teams for optimal pharmacy workload statistics and other pharmacy reports or dashboards.

• Acts as the "super user" of the Pharmacy Revenue Cycle and other reporting tools; provide key input and participation on any system upgrade or enhancement affecting these systems.

• Utilize multiple IT systems to manage analysis, issue research and resolution, and process improvement implementation, including but not limited to: Business Objects, Avalead, etc.

• Perform analysis and data mining of charge, payment, and denials information using analytical tools (Excel, Access) and available reporting; oversee data analysis, trending and management reporting related to Pharmacy Revenue Cycle.

• Actively support initiatives related to Pharmacy Revenue Cycle systems optimization and ensure organizational preparedness and compliance.

• Anticipate and responds to customer needs; follows up until needs are met

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others' ideas and opinions

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

• Use resources efficiently

• Search for less costly ways of doing things

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance