Director – Pharmacy Revenue Cycle - #9820783

Gated Talent

Date: 1 week ago
City: Boston, MA
Contract type: Full time
Role: Director – Pharmacy Revenue Cycle

Location: Boston, MA 02118


  • Pharmacy Revenue Cycle Experiences
  • Bachelors’ Degree in Finance or Business or Financial Management or related field
  • Minimum of 7 years relevant work experience in financial operations required.
  • A minimum of 5 years of management experience required


  • Master’s Degree preferred
  • Lean Six Sigma or equivalent process improvement certification preferred

Essential Responsibilities/Duties

Revenue Cycle Management

  • Directs the activities of the Pharmacy Sr. Manager and Pharmacy Analysts team to ensure operational excellence and delivery of quality patient-focused services in accordance with applicable policies, procedures, and professional standards.
  • Oversees the Third-Party Billing Vendor(s) to ensure billing software and standards are in alignment with established performance metrics to maximize our revenue opportunity and facilitate timely reimbursement.
  • Provides vision and leadership expertise in guiding the complete process of re-engineering Pharmacy Revenue cycle operational processes and procedures as deemed appropriate.
  • Has a firm understanding of the pharmacy cash flow cycle from pharmacy claim submission, to pharmacy payer reimbursement, to bank deposits, to final Finance and associated areas posting of pharmacy revenue to the P&L
  • Responsible for leading the daily billing cycle in all pharmacies, ensuring revenue/charging processes are appropriate and maximized for the benefit of client.
  • Establishes and monitors key performance indicators (KPIs) with monthly report-out to ensure timely billing and collaborate with pharmacy leadership to identify problem accounts and the needed resolution and cascade information to appropriate stakeholders.
  • Develops process for root cause payment variance analysis to identify unpaid or underpaid claims and corrects issues to have those claims paid correctly
  • Manages denial process through denial identification, resolution and systematically eliminates denials through optimized operational or system workflows or processes.
  • Is responsible for leading the on-going system maintenance, upgrades, and testing of all pharmacy related revenue cycle systems or systems that assist in this processes; including the integrity of the Pharmacy charge master.
  • Develops standard performance metrics for the pharmacy’s revenue cycle management. The financial measurements/indicators shall illustrate the positive and negative trends of the pharmacy’s revenue collection.
  • Manages PBM contracts and prepares them for review, renewal, assists with negotiations (e.g. recommending terms and conditions etc.) and ensures all are current for all stores.
  • Leads an on-going review process of the negative trends and investigates the root cause of these trends. Recommends actions for corrections. Communicate trends and corrective action plans to pharmacy leadership and other stakeholders and impact to the bottom line.
  • Leads the enhancement of existing revenue cycle systems or business processes, with the focus being to gain efficiencies and improve revenue collections for the hospital. This includes working closely with the pharmacy managers and senior leaders to enhance and /or eliminate unnecessary manual processes.
  • Responsible for responding to revenue cycle management and pharmacy benefit payer audits. This includes gathering and providing the required documentations to the auditors and payers. Shares back audit results with pharmacy leadership with recommendations on how to avoid penalties if assessed.
  • Works in collaboration with departments (e.g. Finance) to develop and implement automated systems to streamline infrastructure and improve service for all clinical areas

Daily Department Management

  • Responsible for effective fiscal management of departmental operations to ensure proper utilization of departmental financial resources; assists with the departmental budget and manages to budget.
  • Works with other leaders to provide continuous training to the all users, department directors and managers to ensure systems utilization is at maximum capability.
  • Enhances operational protocols and use statistics/metrics to determine overall performance and effectiveness, team performance and error rates, deficits in systems, etc. Communicates those metrics to the Senior Director of Revenue Cycle Operations, VP of Revenue Cycle, Pharmacy Leadership and other stakeholders.
  • Reviews, updates and implements policies and procedures as it relates to the functions of the Pharmacy revenue cycle processes
  • Actively involved in activities to ensure patient and employee satisfaction.
  • Engineers and maintains a Pharmacy Revenue model that supports client and clinical operations
  • Creates and promotes a customer service-oriented work environment
  • Develops new and innovative technology infrastructure to establish and support a high functioning role.
  • Ensures department adapts to regulatory changes in a timely manner.
  • Leads response to applicable audits by governmental or third party payers.
  • Is an active member of the denials and other committees and takes responsibility for generating action plans to increase a better functioning revenue cycle

Human Resources Management

  • Institutes applicable training; initiates updated job requirements/descriptions for all staff; mandatory training, certification, and continual quality audits, e.g. Performance standards
  • Conducts routine department and staff meetings
  • Oversees activities to ensure goals and objectives of the organization are met by specified target dates
  • Creates and fosters a work environment that encourages productivity and work loyalty and employee satisfaction.
  • Conducts performance appraisals for direct report staff and ensures all performance appraisals in department are completed timely.
  • Maintains appropriate staffing levels by planning and working closely with recruiters in Human Resources and the Revenue Cycle Human Resources Business Partner
  • Ensures proper employee orientation, supervision and productivity monitoring
  • Administers coaching and disciplinary measures as needed
  • Evaluates opportunities to automate work functions to reduce cost of doing business associated with labor costs

Meets Hospital-wide Standards In The Following Areas

  • Conforms to hospital standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided.
  • Utilizes hospital’s Values as the basis for decision-making and to facilitate the hospital mission.
  • Follows established hospital infection control and safety procedures
  • Develops competencies as related to position.
  • Performs other tasks as needed



  • Bachelors’ Degree in Finance or Business or Financial Management or related field
  • Master’s Degree preferred

Certificates, Licenses, Registrations Required

  • Lean Six Sigma or equivalent process improvement certification preferred


  • Minimum of 7 years relevant work experience in financial operations required.
  • Specifically, experience in an academic medical center managing physician charging and billing functions preferred.
  • A minimum of 5 years of management experience required.
  • Demonstrated leadership experience in the medical field required

Knowledge And Skills


  • Extensive working knowledge of healthcare applications including, but not limited to Epic, payer websites, QS1, NetRx, Sales Force, etc.
  • Highly skilled experience and knowledge of Windows-based software required, including but not limited to Microsoft Outlook, Word, PowerPoint, and Excel.
  • Comprehensive understanding of retail pharmacy claim adjudication processes and procedures, billing and regulations, guidelines pertaining to third-party payers and self-payers, and health insurance refunds and credit standards.
  • Proficient skills to collect, organize and analyze data, produce actionable reports, and recommend improvements and solutions


  • Proven track record of success in improving pharmacy revenue cycle performance and customer service.
  • Demonstrated leadership skills, with ability to work with multi-departmental teams, peers and third-party vendors.
  • Demonstrated ability to set vision and motivate stakeholders to realize the vision.
  • Solid understanding of business environment and operations.
  • Experienced in auditing, training, and communicating pharmacy revenue cycle regulations and concepts.
  • Ability to be part of a cross-departmental and cross-functional team and participate in the organization and execution of projects.
  • Excellent oral and written communication skills
  • Ability to communicate effectively with both technical and non-technical people


  • Demonstrated ability to supervise all aspects of pharmacy revenue cycle operations and support.
  • Demonstrated ability to motivate staff to perform at the highest possible level.
  • Demonstrated ability to set appropriate priorities for self and staff, and to delegate appropriately.
  • Ability to manage effectively across multiple tasks and projects under time and resource constraints
  • Proven ability to develop policies, procedures, processes, and programs if needed.

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