Pharmacy Adjudication Specialist
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Job Description
Adjudication Specialist managing real time insurance claims while providing customer service to clients. Ensuring compliance with federal and state regulations for CommuniCare Family of Companies.
Responsibilities:
- Manage real time insurance claims while providing customer service to clients
- Analyze and approve claims that need to be adjudicated
- Determine coverage and apply medical necessity guidelines
- Identify and clarify any discrepancies to complete the adjudication process
- Work in cohesion with the CIC Department, Prior Authorization, and Billing Departments
- Submit claims and add appropriate corrections
- Ensure accurate and timely processing of real time claims
- Work directly with third party payers for claim resolution
- Communicate with facilities on claim issues that will need attention by the facility
- Resolve any discrepancies and secure proper reimbursement
- Any other duties associated with adjudication
- Create Prior Authorizations and notify Authorization team
- Follow federal and state regulations
- Adhere to company policies and procedures
- Follow HIPPA guidelines and regulations
Requirements:
- Pharmacy Technician License in Ohio, West Virginia, Indiana, and Maryland (All is preferred, but not required)
- Previous Long-Term Care pharmacy experience a plus (but not required)
- Knowledge of Framework LTC a plus (but not required)
Benefits:
- Comprehensive benefits package, including health, dental, and vision insurance
- 401(k) with company match
- Paid time off
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