Adjudication Specialist

Polaris Pharmacy Services•Covina, CA

6d•$18 - $19•Onsite

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.

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.