Pharmacy Billing and Adjudication Specialist

Ormond Beach, Florida, United States of America Extraordinary Care. Extraordinary Careers. With one of the nation's largest, most innovative long-term care pharmacy services providers, there is no limit to the growth of your career. Guardian Pharmacy of Daytona , a member of the Guardian family of pharmacies, has an exciting opportunity for you to join our rapidly growing team in Ormond Beach, Florida . Why Guardian Pharmacy of Daytona ? We're reimagining medication management and transforming care. Who We Are and What We're About: Our core focus is delivering customized medication management solutions to support healthcare organizations serving seniors and individuals with complex care needs. With our comprehensive suite of tech-enabled pharmacy services and a dedicated team of professionals committed to enriching the lives of those we serve, we are redefining how pharmacy care is delivered. We offer an opportunity to learn and grow your career in a fast-paced, diverse, and inclusive environment. If you are looking for a challenging, team-oriented environment in which you can put your expertise to work, then this is the place for you. Details: Schedule is a varied schedule between 9-5pm and 10-6pm Monday-Friday and every other weekend 8-4pm This role will be performed on-site at a closed-door pharmacy in Ormond Beach, FL. All patient interactions will be over the phone. Looking for someone who is prompt, has attention to detail, problem solving skills, clear communication, teamwork, patience, urgency and confidence We Offer: Comprehensive training provided side by side with training team. We offer full benefits including: Medical, Dental, Vision, Dental, Life Insurance, and a matching 401K option . Competitive pay. ATTRIBUTES REQUIRED: Work Ethic/Integrity - must possess intrinsic drive to excel coupled with values in line with company philosophy Relational - ability to build relationships with business unit management and become "trusted advisor." Strategy and Planning - ability to think ahead, plan and manage time efficiently. Problem Solving - ability to analyze causes and solve problems at functional level. Team Oriented - ability to work effectively and collaboratively with all team members. ESSENTIAL JOB FUNCTIONS (include the following): Research and establish patient eligibility coverage with insurance providers including private individuals and/or government entities. Reverify benefit coverage criteria as needed for claims follow up. Accurately enters and/or updates patient/insurance information into billing system. Maintain and continually audit patient files and corresponding documentation necessary to defend third party audits and ensure payer and company compliance. Accurately enter patient information into the pharmacy system. Provide assistance and timely response to all billing customer inquiries via phone or electronic communications. Research and resolve patient billing issues regarding insurance eligibility, coverage, and related benefits. Provide guidance and support to resident or responsible party by running Medicare plan comparisons during open enrollment and special enrollment periods. Proactively review patient profiles, drug regimens and insurance coverage to evaluate options to save resident money. Responsible for completion of daily census, admit, discharge, and room changes for the facilities assigned. Process patient payments, returns, and credits. Transmit individual credit card payments as needed. May pursue payment from delinquent accounts and make payment arrangements. Research, identify and organize requested audit documentation in timely manner. Perform prescription claims adjudication including communication with insurance companies regarding rejected claims, eligibility, prior authorizations or other issues as needed. Make corrections as needed and rebill claims as necessary. Develop knowledge and understanding in pharmacy facility billing requirements (Medicare, Medicaid, Prescription Drug Plans (PDPs) and Third-Party Insurances) Develop proficiency in the utilization of pharmacy information systems to meet operational needs and regulatory requirements. This includes using pharmacy systems to process prior authorizations, resolve rejections, produce various reports as necessary, and complete billing functions. Rotate through other departments to gain working/functional knowledge of other department workflows. Follow all applicable government regulations including HIPAA. Work as a collaborative team member to meet the service goals of the pharmacy. Other essential functions and duties may be assigned as needed. EDUCATION AND/OR CERTIFICATIONS: High School Diplom #J-18808-Ljbffr guardianpharmacy