Pharmacy Adjudication Specialist

Claim Adjudication Department Specialist

Reports to: Adjudication Specialist Supervisor

Job Type: Full-Time – Remote – Pharmacies located in: West Virginia, Ohio, Indiana, and Maryland

Position Overview: As the Adjudication Specialist, you will manage real time insurance claims, while providing customer service to clients. Analyze and approve claims that need to be adjudicated. Determine coverage and apply medical necessity guidelines. Identify and clarify any discrepancies to complete the adjudication process.

Key Responsibilities Include but are not limited to:

• Work in cohesion with the CIC Department, Prior Authorization, and Billing Departments
• Submit claims and add appropriate corrections
• Ensure accurate and timely processing of real time claims
• Work directly with third party payers for claim resolution
• Communicate with facilities on claim issues that will need attention by the facility
• Resolve any discrepancies and secure proper reimbursement
• Any other duties associated with adjudication
• Create Prior Authorizations and notify Authorization team
• Follow federal and state regulations
• Adhere to company policies and procedures
• Follow HIPPA guidelines and regulations

Qualifications and Requirements:

• Pharmacy Technician License in Ohio, West Virgina, Indiana, and Maryland (All is preferred, but not required)
• Previous Long-Term Care pharmacy experience a plus (but not required)
• Knowledge of Framework LTC a plus (but not required)

Salary and Benefits:

• Competitive salary commensurate with experience
• Comprehensive benefits package, including health, dental, and vision insurance, 401(k) with company match, paid time off, and more