Pharmacy Billing Specialist Adjudication

St. Petersburg, Florida, United States of America Guardian Pharmacy of Tampa, a member of the Guardian family of pharmacies, is offering a position in St. Petersburg, Florida. Schedule: M‑F 12pm‑8pm; every other weekend rotation 9am‑5pm. Essential Job Functions: 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 enter and/or update patient/insurance information into the 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. Assist residents or responsible parties 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. Perform daily census, admit, discharge, and room changes for the assigned facilities. Process patient payments, returns, and credits. Transmit individual credit card payments as needed. Pursue payment from delinquent accounts and make payment arrangements. Research, identify, and organize requested audit documentation in a 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. Develop knowledge and understanding of pharmacy facility billing requirements (Medicare, Medicaid, Prescription Drug Plans, and Third‑Party Insurances). Develop proficiency in the utilization of pharmacy information systems to meet operational needs and regulatory requirements, including processing prior authorizations, resolving rejections, producing reports, and completing billing functions. Rotate through other departments to gain functional knowledge of other workflow processes. 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. Attributes Required: Work ethic and integrity—intrinsic drive to excel coupled with values aligned with company philosophy. Relational—ability to build relationships with business unit management and become a trusted advisor. Strategy and planning—ability to think ahead, plan, and manage time efficiently. Problem solving—ability to analyze causes and solve functional‑level problems. Team oriented—ability to work effectively and collaboratively with all team members. Education and/or Certifications: High School Diploma or GED required. Pharmacy Technician license/certification/registration per state requirements; National Certification preferred (PTCB); may be required. Skills and Qualifications: At least 1 year of related experience. Advanced computer skills; pharmacy information system experience preferred. Ability to work independently and meet deadlines. Great attention to detail and accuracy. Ability to excel in a fast‑paced, team‑oriented environment, handling multiple tasks simultaneously while adhering to strict deadlines. Quality‑minded; motivated to identify errors and inquire about inaccuracies. Work Environment: Noise level: low to moderate. Requires effective interaction with others in an office setting, conflict management, and handling stressful situations and deadlines. Desk work in office environment. Flexibility to work non‑standard hours. Benefits: Competitive pay. 401(k) with company match. Medical, dental, and vision (Full‑time employees working 30+ hours/week). Health Savings Accounts and Flexible Spending Accounts. Company‑paid basic life and accidental death & disability. Company‑paid long‑term disability and optional short‑term disability. Voluntary employee and dependent life, accident, and critical illness. Dependent care flexible spending account. Employee Assistance Program (EAP). Guardian Angels (employee assistance fund). Paid holidays and sick days. Generous vacation benefits based on years of service. #J-18808-Ljbffr