Adjudication Specialist
Description:
Job Details
Polaris Pharmacy Services of Ohio - Columbus, OH
Full Time
Pharmaceutical
Description
THIRD PARTY ADJUDICATION CLAIMS SPECIALIST
WHO WE ARE
Polaris Pharmacy Services is an industry leader in both the Long-Term Care and Post-Acute Care settings. Founded in 2015, we are locally and independently owned with pharmacies in different cities through-out the United States. We are proud to offer competitive benefits and industry pay as well as the opportunity for career advancement to all our team members.
OVERVIEW
The Third-Party Adjudication Claims Specialist is responsible for managing and identifying a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks to Polaris and their customers. The Third-Party Adjudication Claims Specialist must be responsive and courteous when addressing our customers needs. Successful Specialists are dedicated to meeting the expectations and requirements of the position; understanding customer information and using it to improve products and services we deliver; talking and acting with customers in mind; establishing and maintaining effective relationships with co-workers and customers, thus gaining our customers trust and respect.
RESPONSIBILITIES
Manage and identify a portfolio of rejected pharmacy claims to ensure maximum payer reimbursement and timely billing to eliminate financial risks to Polaris and their customers
Research, analyze and appropriately resolve rejected claims by working with national Medicare D plans, third party insurance companies, and all state Medicaid plans to ensure maximum payer reimbursement adhering to critical deadlines
Ensure approval of claims by performing appropriate edits and/or reversals to ensure maximum payer reimbursement
Contact providers and/or customers as necessary to obtain additional information
Monitor and resolve revenue at risk associated with payer set up, billing, rebilling, and reversal processes
Work as a team to identify, document, communicate, and resolve payer/billing trends and issues
Complete, communicate, and submit necessary payer paperwork, including but not limited to prior authorizations forms and manual billing in a timely manner
Review and work convert billing exception reports to ensure claims are billed to accurate financial plans
Complete billing transactions for non-standard order entry situations as required
Support training needs
Prepare and maintain reports and records for processing
Perform other tasks as assigned.
Follow all applicable government regulations, including HIPAA
Comply with departmental policies regarding safety, attendance, and dress code
Overtime, holidays, and weekends may be required and/or expected
Conduct job responsibilities in accordance with the standards set out in the Companys Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards
Other duties as assigned; Job duties may vary depending on business needs
Qualifications
QUALIFICATIONS
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)
Framework LTC & General computer knowledge & 10-key Number Entry preferred
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
PHYSICAL DEMANDS
The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job:
May sit or stand seven (7) to ten (10) hours per day
The employee is occasionally required to sit; climb or balance; and stoop, kneel, bend, crouch, walk, crawl intermittently
May be necessary to work extended hours as needed
May lift and/or move up to 50 pounds
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role
HOLIDAY & PTO POLICY
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.
Please note, because we are a pharmacy most of our locations are open 24-hours a day, 7 days a week and therefore schedules may change as determined by the needs of the business.
BENEFITS for full time employees
Medical, Dental, Vision and Life insurance
401 (k) (available for Part Time & Full Time EEs)
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