Adjudication Specialist

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🕒 5 dias atrás

🐊 Florida – Remoto

🐊 Florida – Remote

⏰ Tempo Integral

🟢 Júnior

🚫👨‍🎓 Sem graduação necessária

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Polaris Pharmacy Services

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 2015

💼 Consultoria

🏭 Manufatura

📦 Logística

Consulting • Manufacturing • Logistics

A Polaris Pharmacy Services é uma farmácia de cuidados de longo prazo e pós-agudos, de propriedade privada, comprometida em oferecer serviços farmacêuticos de alta qualidade, experiências excepcionais aos clientes e um valor líder no setor. Você sabia que a Polaris é a 5ª maior farmácia de LTC nos EUA, oferecendo cuidados de alta qualidade para instalações de LTC, PACE e Correção? Fundada em 2015, a Polaris opera 21 farmácias em 29 estados, atendendo mais de 80.000 residentes e fornecendo soluções inovadoras em embalagem, reembolso, fluxo de trabalho e desempenho financeiro.

Descrição

• Manage and identify a portfolio of rejected pharmacy claims • Review and evaluate insurance claims for insurer liability under policy provisions and state and federal regulations • Authenticate claimants and verify claim submission documents to prevent fraud and ensure compliance • Calculate benefit payments and approve claim settlements based on coverage and assessment findings • Coordinate with healthcare providers, repair services, and other parties to obtain documentation • Negotiate settlements for disputed claims • Monitor and resolve revenue risks involving payer setup, billing, rebilling, and reversals • Interpret and apply complex insurance policy language • Explain adjudication processes, claim denials, and settlement offers to claimants • Implement alternative dispute resolution methods when needed • Complete payer paperwork, prior authorization forms, and manual billing • Handle non-standard order entry situations • Support team training needs

🎯 Requisitos

• 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 experience preferred • Able to read, write, speak, and understand English • Able to retain and apply a large amount of information • Able to work in a fast-paced environment • Basic computer knowledge required • Basic math and analytical skills • Experience with alpha-numeric data entry • Proficient in Microsoft Word, Excel, and Outlook required • Customer service and results-oriented approach • Good organization and attention to detail • Reliable problem solver • Able to work various shifts and days • Adaptable to an ever-changing environment • Framework LTC, general computer knowledge, and 10-key number entry preferred • May sit or stand seven to ten hours per day • May work extended hours as needed • May lift and/or move up to 30 pounds

🏖️ Benefícios

• Paid holidays: 6 days annually • 5 sick days annually • Up to 10 PTO days each year • PTO rollover options and milestone bonuses • Option to cash out up to 10 PTO hours each quarter • 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 • Competitive pay with annual performance reviews and merit-based raises • Career growth potential • Annual on-site voluntary Flu Vaccines • Employee referral bonus program