Adjudication Specialist – Seasonal

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

📋 Description

• Oversee and identify a portfolio of denied pharmacy claims.

• Examine and assess insurance claims to establish insurer liability while adhering to policy provisions and state and federal regulations.

• Verify claimants and authenticate claim submission documents to prevent fraud and maintain compliance.

• Calculate benefit payments and authorize claim settlements based on coverage and evaluation outcomes.

• Collaborate with healthcare providers, repair services, and other entities to gather documentation for claim resolution.

• Negotiate settlements for disputed claims.

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

• Interpret and apply intricate insurance policy language to claim scenarios.

• Clarify the adjudication process, claim denials, and settlement offers to claimants.

• Employ alternative dispute resolution methods as necessary.

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

• Manage non-standard order entry situations.

• Assist in meeting team training requirements.

• Work schedules and responsibilities may vary based on business needs; extended hours may be necessary.

⛳️ Requirements

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

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

• Ability to thrive in a fast-paced environment.

• Basic computer proficiency.

• Fundamental math and analytical skills.

• Experience with alphanumeric data entry.

• Skilled in Microsoft Word, Excel, and Outlook.

• Strong customer service abilities.

• Results-driven and organized, with a keen attention to detail.

• Dependable problem solver.

• Available to work various shifts and days.

• Flexible in adapting to a constantly changing environment.

• High school diploma or equivalent is required.

• Minimum of 1 year experience working as a pharmacy technician in a retail setting is required; long-term care pharmacy experience is preferred.

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

• May be required to sit or stand for 7–10 hours per day.

• May need to lift and/or move up to 30 pounds.

🏝️ Benefits

• Paid holidays: 6 days per year.

• 5 sick days per year.

• Up to 10 PTO days annually, with rollover options and milestone bonuses.

• Option to cash out up to 10 PTO hours every quarter.

• Medical insurance.

• Dental insurance.

• Vision insurance.

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

• Company-paid life insurance.

• Short-term disability insurance.

• Long-term disability insurance.

• Tuition reimbursement.

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

• Opportunities for career advancement.

• Annual on-site voluntary flu vaccinations.

• Employee referral bonus program.