Adjudication Specialist - Remote

Polaris Pharmacy Services•Fort Lauderdale, FL

9d•Remote

About The Position

The Adjudication Specialist manages a portfolio of rejected pharmacy claims, ensuring timely billing and maximum payer reimbursement. They prioritize customer needs, maintain courteous communication, and build effective relationships with colleagues and clients. Their goal is to uphold customer trust and enhance our services. Polaris Pharmacy Services is a dedicated partner in care, transforming how patients experience long-term, post-acute, correctional, PACE, and specialty pharmacy services. As industry leaders, we’re raising the bar for quality and coordination across all sites of care, ensuring every patient receives seamless, compassionate, and expert support. Founded in 2015, Polaris is proud to be locally and independently owned, with a growing national footprint. Our team thrives in a mission-driven environment where innovation meets purpose, and every role contributes to making a real impact. We offer more than just a job — we provide competitive pay, robust benefits, and genuine opportunities for career advancement.

Requirements

Able to read, write, speak, and understand the English language
Able to retain a large amount of information and apply that knowledge to related situations
Able to work in a fast-paced environment
Basic computer knowledge skills required
Basic math and analytical skills
Experience with alpha-numeric data entry
Proficient in Microsoft Word, Excel, and Outlook required
Customer Service
Results-oriented
Good organization/Attention to detail
Reliable
Problem solver
Able to work various shifts and days
Adaptability to an ever-changing environment
High School diploma or equivalent required
Minimum of one (1) or more years working as a pharmacy technician in a retail environment required (long-term care pharmacy preferred)

Nice To Haves

Framework LTC & General computer knowledge & 10-key Number Entry preferred

Responsibilities

Manage and Identify Claims Portfolio: Review and evaluate insurance claims to determine the extent of the insurer’s liability, adhering to policy provisions and state and federal regulations.
Authenticate claimants and verify the accuracy of claim submission documents to prevent fraud and ensure compliance with policy terms.
Resolve Rejected Claims: Calculate benefit payments and approve claim settlements based on policy coverage and assessment findings.
Coordinate with healthcare providers, repair services, or other parties to obtain additional documentation necessary for claim resolution.
Effective Communication and Risk Management: Negotiate settlements with claimants or their representatives in cases of disputed claims.
Monitor and resolve revenue risks associated with payer setup, billing, rebilling, and reversal processes.
Policy Interpretation and Compliance: Interpret and apply complex insurance policy language to diverse claim scenarios.
Provide detailed explanations to claimants regarding the adjudication process, claim denials, or settlement offers
Implement alternative dispute resolution methods when conventional negotiation does not achieve a settlement.
Complete necessary payer paperwork, including prior authorization forms and manual billing.
Handle non-standard order entry situations as required.
Support training needs within the team.
Duties may vary depending on business needs and operational context.

Benefits

Medical, Dental, and Vision insurance
401 (k) (available for Part Time & Full Time EEs)
Company Paid Life insurance
Short-term and Long-term disability insurance
Tuition reimbursement
Personal Time Off (PTO)
Competitive pay with annual performance reviews and merit-based raises
Career growth potential
Annual on-site voluntary Flu Vaccines
Employee referral bonus program
Paid holidays are provided annually, with 6 days offered each year, along with 5 sick days.
Employees earn up to 10 PTO days each year, with rollover options and milestone bonuses.
Employees have the option to cash out up to 10 PTO hours each quarter for added financial flexibility.