Position Summary

The Process Control Specialist supports pharmacy-benefit revenue integrity across retail and specialty pharmacy services. The position is responsible for pharmacy claim review, reimbursement monitoring, audit coordination, billing issue resolution, rebilling activities, and identification of reimbursement improvement opportunities.

The role collaborates with Pharmacy Operations, Revenue Cycle, Compliance, Managed Care, Finance, 340B, and Information Technology to help ensure claims are billed accurately, payer requirements are understood, reimbursement concerns are investigated, and financial risk is identified and addressed.

This position serves as a pharmacy-benefit billing and reimbursement resource and supports the Pharmacy Business Office roadmap through revenue protection, audit readiness, pricing oversight, reimbursement monitoring, operational education, and continuous improvement.

Essential Responsibilities

Pharmacy-Benefit Claim Review and Revenue Integrity

• Review pharmacy-benefit claims for billing accuracy, appropriate claim submission, and reimbursement concerns.
• Monitor daily and recurring exception reports, including negative reimbursement, paid claim duplicates, rejected reversals, marked reversals, continuation-on-failure activity, bill-later claims, test claims, high-dollar claims, cash-plan use, workers compensation claims, and other identified exceptions.
• Review Medicare Part B and durable medical equipment claims for billing accuracy, overrides, required documentation, and potential compliance concerns.
• Investigate claim rejections, reversals, coordination-of-benefits issues, dispense-as-written code use, payer overrides, and other adjudication concerns.
• Coordinate rebilling and claim-correction requests and help drive identified issues through resolution.
• Identify recurring claim defects, reimbursement leakage, and operational trends that require education, workflow changes, or escalation.

Payer Audits and Compliance Support

• Coordinate commercial, government, pharmacy benefit manager, and other payer audit requests.
• Collect, review, organize, and track documentation needed for desk audits and claim-level audits.
• Maintain audit readiness through proactive claim monitoring, documentation standards, and operational education.
• Partner with Compliance, Legal, pharmacy leaders, and operational teams when payer requirements or billing practices require interpretation.
• Support standardized Medicare Part B documentation, checklists, procedures, and audit-preparedness materials.
• Track audit findings and assist with corrective-action follow-through.

Reimbursement and Pricing Monitoring

• Monitor reimbursement results and investigate underpayments, negative payments, unexpected patient responsibility, and other payment variances.
• Compare claim reimbursement with acquisition cost and available pricing information to identify potential margin concerns.
• Support pharmacy pricing monitoring, payer-rule review, and identification of reimbursement improvement opportunities.
• Escalate systemic payer, pricing, or configuration issues and collaborate with the appropriate teams through resolution.
• Assist with trend reporting, financial impact assessment, and measurement of corrected or avoided revenue loss.
• Support the Pharmacy Business Office feedback loop connecting payer terms, operational workflow, claim outcomes, payment, and margin.

Operational Support, Education, and Process Improvement

• Serve as a resource to retail and specialty pharmacy teams for billing, adjudication, rejection, rebilling, and reimbursement questions.
• Develop clear procedures, tip sheets, checklists, and education related to identified billing risks and payer requirements.
• Work with pharmacy leaders and frontline staff to standardize processes and reduce repeated billing defects.
• Identify opportunities to improve reports, workflows, controls, and issue-escalation processes.
• Participate in Pharmacy Business Office initiatives and cross-functional work related to pharmacy-benefit revenue integrity.
• Maintain organized documentation of investigations, decisions, follow-up actions, and completed improvements.

Required Knowledge and Skills

• Strong understanding of pharmacy-benefit claim adjudication from submission through reversal, rebilling, and final reimbursement.
• Knowledge of retail and specialty pharmacy billing workflows and common payer rejection scenarios.
• Knowledge of Medicare Part B, Medicare Part D, Medicaid, commercial payer, and pharmacy benefit manager requirements as they relate to pharmacy billing.
• Working knowledge of NCPDP transactions, coordination of benefits, dispense-as-written codes, overrides, days-supply requirements, payer edits, and claim reversals.
• Ability to interpret payer guidance, contracts, claim responses, audit requests, and billing requirements.
• Ability to analyze claim-level data, recognize patterns, conduct root-cause analysis, and distinguish isolated errors from systemic issues.

• Ability to connect operational billing decisions to reimbursement, compliance, patient impact, and margin.
• Ability to manage competing priorities, recurring controls, audit deadlines, and urgent billing issues with limited supervision.
• Strong written and verbal communication skills, including the ability to explain technical billing issues in practical language.
• Demonstrated collaboration across Pharmacy Operations, Revenue Cycle, Compliance, Finance, Managed Care, 340B, and technical teams.
• Proficiency with Microsoft Excel, including sorting, filtering, lookups, pivot tables, reconciliation, and basic data analysis.
• Ability to learn and effectively use pharmacy dispensing, claim-management, reporting, and analytics systems.

Preferred Background and Development Potential

• Pharmacy technician experience in retail, specialty, health-system, or another pharmacy setting. Direct pharmacy billing, revenue integrity, payer audit, reimbursement, or pharmacy benefit manager experience is helpful but not required.
• Exposure to rejected claims, rebills, reversals, insurance processing, or payer-specific billing issues is preferred. Candidates who demonstrate the ability and desire to learn these functions should also be considered.
• Experience supporting audits or documentation requests is preferred and may be developed through training.
• Experience with Medicare Part B pharmacy billing is preferred but may be learned on the job by a candidate with a strong pharmacy foundation.
• Interest in learning reimbursement, acquisition-cost comparisons, pricing monitoring, and margin improvement is expected; prior experience is preferred but not required.
• Experience developing procedures, training materials, reporting, or standard work.
• Experience with Epic, WAM, Microsoft Power BI, Databricks, or comparable pharmacy and analytics tools.
• Pharmacy technician background required or strongly preferred based on the established system job requirements; Certified Pharmacy Technician credential preferred when applicable.
• Healthcare, pharmacy, business, finance, analytics, or related education preferred when consistent with the system job requirements.

Candidate Profile

The successful candidate may be an experienced pharmacy technician who understands pharmacy operations, demonstrates strong attention to detail, and has the desire and ability to learn pharmacy-benefit billing, payer requirements, audits, reimbursement, pricing, and revenue integrity. Prior experience in every area is not required. The individual should be curious, dependable, comfortable investigating issues, and willing to develop the knowledge needed to move concerns from identification through resolution. More experienced candidates may bring direct billing or reimbursement expertise, but a pharmacy technician with strong potential and a learning mindset should also be considered.

Key Attributes for Candidate Selection

Selection priority: When direct reimbursement experience is limited, prioritize pharmacy knowledge, reliability, critical thinking, attention to detail, communication, basic data aptitude, and demonstrated willingness to learn.

• Pharmacy-benefit expertise: Understands adjudication, payer rules, claim responses, rebilling, and reimbursement.
• Investigative judgment: Asks the right questions, validates facts, and follows issues to a supported conclusion.
• Analytical capability: Uses claim and reimbursement data to identify trends, quantify impact, and prioritize work.
• Operational credibility: Can provide practical guidance to pharmacy staff and understands frontline workflow implications.
• Ownership: Maintains controls, documents work, meets deadlines, and escalates material risks appropriately.
• Collaboration: Builds productive working relationships without shifting blame between Pharmacy and partner teams.
• Continuous-improvement mindset: Looks beyond completing reports to reducing recurrence and improving financial outcomes.
• Communication: Clearly explains the issue, impact, recommended action, owner, and needed follow-up.

Suggested Interview Focus

• Ask the candidate to walk through how they would investigate a paid pharmacy claim with negative reimbursement.
• Use a scenario involving a claim rejection, reversal, or rebill and assess whether the candidate can identify the next questions, data, and partners needed.
• Ask for an example of an audit or compliance concern they managed and how they organized documentation and follow-up.
• Assess Excel capability using a practical claim-review or reconciliation exercise.
• Ask how the candidate distinguishes a single claim error from a trend requiring workflow, education, payer, or system intervention.
• Explore whether the candidate can explain a complex billing problem to frontline pharmacy staff and to a non-pharmacy business partner.
• Assess interest and aptitude for expanding from operational claim review into pricing, reimbursement, and margin monitoring.