Manager of Pharmacy Revenue Integrity

Company: Mercyhealth
Location: Janesville
Posted on: May 14, 2025

Job Description:

Overview:

All potential candidates should read through the following details of this job with care before making an application.

This position will be onsite at our Janesville, WI campus.

Pharmacy revenue integrity is integral to the financial health of Mercyhealth. The Manager of Pharmacy Revenue Integrity will be responsible for developing strategies and workflows to maximize pharmacy revenue opportunities in the professional (clinic), hospital billing, and community pharmacy spaces. The Pharmacy Revenue Integrity Manager will serve as a pharmacy liaison and interface with finance, billing, revenue integrity, patient financial services, prior authorization teams, denial specialists, compliance, and other key stakeholders. This individual will serve as a subject matter expert in the setting of medication-related compliance billing and charging processes.

Responsibilities:

ESSENTIAL DUTIES AND RESPONSIBILITIES

Serves as a liaison between finance, revenue cycle, compliance, pharmacy, and other departments to standardize and optimize pharmacy charging workflows, pharmacy revenue charge capture, denial management and collections.
Drive accuracy for all HCPCS/CPT codes, revenue codes, billable units, multipliers, and modifiers. Partners with DTS, pharmacy leadership, finance, and others to resolve discrepancies.
Develop quality metrics, audit methodologies and analyzes pharmacy revenue reports to ensure accurate billing and revenue captures.
Partners with pharmacy operational leadership to analyze pharmacy revenue and volume data. Identify and aggregate variance explanations to provide to finance and senior executive leadership.
Builds tools to audit and ensure the accuracy of data feeds from EPIC to third party vendors.
Actively researches and stays current with important billing and revenue related compliance and optimization strategies.
Maintain a thorough understanding of 340B program regulations and compliance requirements, staying up to date on policy changes and industry best practices to ensure accurate revenue integrity and optimal program utilization.
Develop policies, guidelines, and procedures for pharmaceutical coding, billing, pricing, charging, and denial management to maximize reimbursement and compliant charging.
Provides education to site and system stakeholders to drive optimal revenue capture.
Perform quality reviews to ensure that medication formulary additions, inactivation's, changes and/or revisions were accurately completed in the hospitals clinical and financial systems.
Participate and lead committees, work groups, process improvement efforts, and educational initiatives to improve pharmacy revenue integrity and the pharmacy billing cycle.
Review of charging algorithms and standardization across the organization as well as input into annual adjustment to said algorithms.
Review of the cost structures in EPIC for applicability.

CULTURE OF EXCELLENCE BEHAVIOR EXPECTATIONS

To perform the job successfully, an individual should demonstrate the following behavior expectations:

Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals.

Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions.

Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals.

Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue.

EDUCATION & EXPERIENCE

Required:

BS in Pharmacy or PharmD
Three years of health-system pharmacy experience or completion of a PGY2 residency program in health-system pharmacy administration and leadership.
Experience in the field of pharmacy revenue integrity.

Preferred:

Previous leadership experience with demonstrated responsibility for financial performance
Experience with EPIC or EPIC certified

CERTIFICATION/LICENSURE

Licensed or eligible for licensure as a pharmacist in the State of Wisconsin and State of Illinois

ADDITIONAL REQUIREMENTS

Passing the Driver's License Check and/or Credit Check (for those positions requiring).
Passing the WI Caregiver Background Check and/or IL Health Care Workers Background Check.
Must be able to follow written/oral instructions.

OTHER SKILLS AND ABILITIES

Proficiency in the use of Microsoft Office Suite and other similar applications as appropriate to area of expertise.
Exemplifies strong organizational, time management, leadership, conflict management, and change management skills.
Advanced knowledge of health-system pharmacy operations including the ability to navigate the electronic medical record within EPIC.
Ability to problem solve and proactively address issues, resulting in positive outcomes.
Able to interpret large amount of data for strategic decision making.
Understanding of and partnering with 340B and Specialty Pharmacy program teams.

WORK ENVIRONMENT

The noise level in the work environment is usually moderate. Occupational exposure is Category C, which means no employees in the specified job classifications have occupational exposure.

INFORMATION ACCESS

Partner may access patient care information, financial data, human resource data and strategic and planning data needed to perform their job duties as directed by the director.

WORK CONTACT GROUP

Pharmacy, finance, revenue integrity, 340B team and clinic/hospital leadership.

SPECIAL PHYSICAL DEMANDS

The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations.

Frequently required to stand, sit, walk, bend, and reach for supply items.

Occasionally required to lift up to 10 pounds

Specific vision abilities: Near and far vision, color vision, peripheral vision, depth perception, focus adjustment.

LEVEL OF SUPERVISION

Works independently under the supervision of the System Director of Pharmacy

SUPERVISES

No direct reports. Supervisory responsibilities are conducted in accordance with directives of management, the organization's policies, and applicable laws.

#MHP123

Culture of Excellence Behavior Expectations:

Benefits:

Mercyhealth offers a generous total rewards package to eligible employees including, but not limited to:

- Comprehensive Benefits Package: Mercyhealth offers a retirement plan with competitive matching contribution, comprehensive medical, dental, and vision insurance options, life and disability coverage, access to flexible spending plans, and a variety of other discounted voluntary benefit options.

- Competitive Compensation: Mercyhealth offers market competitive rates of pay and participates in various shift differential and special pay incentive programs.

- Paid Time Off: Mercyhealth offers a generous paid time off plan, which increases with milestone anniversaries, to allow employees the opportunity for a great work-life balance.

- Career Advancement: Mercyhealth offers a number of educational assistance programs and career ladders to support employees in their educational journey and advancement within Mercyhealth.

- Employee Wellbeing: Mercyhealth has a focus on wellbeing for employees across the organization and offers a number of tools and resources, such as an employer-sponsored health risk assessment and a Wellbeing mobile application, to assist employees on their wellbeing journey.

- Additional Benefits: Mercyhealth employees have access to our internal and external employee assistance programs, employee-only discount packages, paid parental and caregiver leaves, on-demand pay, special payment programs for patient services, and financial education to help with retirement planning.

Keywords: Mercyhealth, Carol Stream , Manager of Pharmacy Revenue Integrity, Healthcare , Janesville, Illinois