Adjudication Specialist (1PM - 9:30 PM CST, ROTATING WEEKENDS/HOLIDAYS )

Job Summary

The Adjudication Specialist is responsible for submitting and adjudicating third-party prescription claims in real time and resolving claim rejections or issues that impact timely billing and delivery of medications to long-term care (LTC) facilities. This role focuses on accurate claim processing, timely follow-up on denials and prior authorizations, effective communication with facilities, authorized representatives, and payers, and adherence to established policies, procedures, and payer requirements. The Adjudication Specialist plays a critical role in supporting revenue integrity, minimizing write-offs, and ensuring uninterrupted patient care.

Education & Experience Requirements

· High school diploma or equivalent required.

· Prior experience in pharmacy adjudication, billing, or healthcare revenue cycle preferred.

· Long-term care pharmacy experience strongly preferred.

· Current State Pharmacy Technician license required.

· Experience with FrameworkLTC preferred.

· Strong attention to detail and accuracy.

· Effective analytical and problem-solving skills.

· Ability to manage multiple priorities in a fast-paced environment.

· Strong written and verbal communication skills.

· Professional, customer-focused demeanor.

· Ability to work independently and collaboratively.

Essential Job FunctionsClaim Processing & Adjudication

· Review, submit, and adjudicate third-party prescription claims accurately and efficiently in real time.

· Identify, troubleshoot, and resolve denied or rejected claims in a timely manner which may include outbound calls for resolution.

· Work claims in accordance with established timelines, payer rules, and internal policies and procedures.

· Initiate prior authorizations as required based on claim rejections, payer requirements, or medication criteria.

· Follow up on pending prior authorizations with prescribers, facilities, and third-party payers to ensure timely resolution.

· Rebill rejected or reversed claims throughout the shift as scheduled.

· Run and work assigned reports, including Negative Margin Reports and other daily adjudication-related reports, as directed.

· Provide facility price quotes as requested by staff at LTC facilities

· Process new admissions throughout the day, verifying payer status to accurately determine medication quantities and appropriate days’ supply.

· Any and all other duties as assigned by leadership team.

Communication & Documentation

· Communicate professionally and effectively with facility staff, residents, authorized representatives, powers of attorney, third-party payers, prescribers, and internal team members.

· Correspond with designated facility staff regarding high-dollar medication approvals, prior authorizations, and adjudication-related issues.

· Provide clear and timely updates to customers regarding claim status, delays in sending medications, prior authorization status.

· Create and distribute communication memos regarding billing or adjudication issues to facility management and nursing staff when required.

· Document claim activity, prior authorization status, payer communications, and facility-specific requirements accurately for follow-up and audit purposes.

· Update reference materials as needed and share payer rule changes with teammates and management.

Workflow Support & Prioritization

· Work according to facility delivery schedules and prioritize claims to support on-time medication delivery.

· Support preparation and expediting of STAT and urgent deliveries.

· Assist other team members to maintain workflow and department productivity.

· Demonstrate strong time-management, multitasking, and communication skills to effectively collaborate with team members, maintain workflow efficiency, and meet delivery deadlines.

Compliance & Professional Standards

· Follow established guidelines, payer-specific requirements, and facility-specific billing instructions.

· Maintain an active State Pharmacy Technician license in good standing.

· Obtain PTCB or ExCPT certification within 12 months of hire if newly licensed; ensure timely renewals if certified.

· Adhere to all company’s policies, procedures, and code of conduct.

Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time as needed.

Job Type: Full-time

Pay: $21.89 - $29.50 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off

Application Question(s):

• Are you willing to work 2PM -10:30PM CST with rotating weekends?

License/Certification:

• Are you a licensed pharmacy technician? (Preferred)

Shift availability:

• Night Shift (Preferred)

Work Location: Remote