Adjudication Specialist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Oversee and assess a portfolio of rejected pharmacy claims.

• Analyze and determine insurance claims for liability in accordance with policy terms as well as state and federal regulations.

• Verify claimants and validate claim submission documents to mitigate fraud and ensure adherence to compliance standards.

• Calculate benefit payments and authorize claim settlements based on coverage details and assessment results.

• Collaborate with healthcare providers, repair services, and other stakeholders to acquire necessary documentation.

• Negotiate settlements for contested claims.

• Monitor and address revenue risks related to payer setup, billing, rebilling, and reversals.

• Interpret and apply intricate insurance policy language.

• Clearly communicate adjudication processes, claim denials, and settlement proposals to claimants.

• Apply alternative dispute resolution methods when necessary.

• Complete payer-related documentation, prior authorization forms, and manual billing tasks.

• Manage non-standard order entry situations.

• Assist with team training requirements.

⛳️ Requirements

• High School diploma or equivalent is mandatory.

• At least one (1) year of experience as a pharmacy technician in a retail setting is required.

• Experience in long-term care pharmacy is preferred.

• Proficient in reading, writing, speaking, and understanding English.

• Capable of retaining and applying a considerable amount of information.

• Ability to thrive in a fast-paced work environment.

• Basic computer skills are essential.

• Fundamental math and analytical abilities are necessary.

• Experience with alpha-numeric data entry is required.

• Proficient in Microsoft Word, Excel, and Outlook.

• Customer service-oriented with a focus on achieving results.

• Strong organizational skills and attention to detail.

• Reliable problem-solving skills.

• Availability to work various shifts and days.

• Adaptable to a constantly changing environment.

• Familiarity with Framework LTC, general computer knowledge, and 10-key number entry is preferred.

• Must be able to sit or stand for seven to ten hours per day.

• May be required to work extended hours as necessary.

• Able to lift and/or move up to 30 pounds.

🏝️ Benefits

• Paid holidays: 6 days each year.

• 5 sick days annually.

• Up to 10 PTO days each year.

• Options for PTO rollover and milestone bonuses.

• Ability to cash out up to 10 PTO hours each quarter.

• Medical, Dental, and Vision insurance coverage.

• 401(k) plan available for both Part Time & Full Time employees.

• Company-paid Life insurance.

• Short-term and Long-term disability insurance options.

• Tuition reimbursement program.

• Competitive salary with annual performance evaluations and merit-based salary increases.

• Opportunities for career advancement.

• Annual on-site voluntary flu vaccinations.

• Employee referral bonus program.