Adjudication 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 nationwide. We are proud to offer competitive benefits and industry pay as well as the opportunity for career advancement to all our team members.

JOB SUMMARY:

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.

DUTIES/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
•  Additional Responsibilities:
• 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.

QUALIFICATIONS/COMPETENCIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

REQUIRED SKILLS/ABILITIES:

• 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