Pharmacy Adjudication Specialist

This is a fully remote position, open to applicants in Ohio, +3 more states.

📋 Description

• Oversee real-time insurance claims while delivering exceptional customer service to clients.

• Evaluate and approve claims requiring adjudication.

• Assess coverage and implement medical necessity criteria.

• Identify and resolve any inconsistencies to finalize the adjudication process.

• Collaborate effectively with the CIC Department, Prior Authorization, and Billing Departments.

• Submit claims and make necessary corrections.

• Ensure precise and prompt processing of real-time claims.

• Engage directly with third-party payers to resolve claims issues.

• Liaise with facilities regarding claim matters that require their attention.

• Address any discrepancies and secure appropriate reimbursement.

• Perform other tasks related to adjudication as required.

• Generate Prior Authorizations and inform the Authorization team.

• Comply with federal and state regulations.

• Follow company policies and procedures diligently.

• Adhere to HIPAA guidelines and regulations.

⛳️ Requirements

• Pharmacy Technician License in Ohio, West Virginia, Indiana, and Maryland (All are preferred, but not mandatory).

• Previous experience in Long-Term Care pharmacy is advantageous (but not essential).

• Familiarity with Framework LTC is beneficial (but not required).

🏝️ Benefits

• Comprehensive benefits package, including health, dental, and vision insurance.

• 401(k) with company match.

• Paid time off.