Pharmacy Process Control Specialist-Pharmacy Business Office

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 At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally.

In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Personify Health Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.

St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law. *Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.