Claims Adjudicator

About AmeriPharma

AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.

AmeriPharma’s Benefits

• Full benefits package including medical, dental, vision, and life
• Great pay and general compensation structures
• Employee assistance program to assist with mental health, legal questions, financial counseling, etc.
• Comprehensive PTO and sick leave options
• 401k and matching programs
• Plenty of opportunities for growth and advancement
• Company sponsored outings and team-building events
• Casual Fridays

Schedule Details

• Location: On-Site (Laguna Hills, CA)
• Hours: Monday to Friday, 8:30 AM - 5:00 PM

Job Summary

The Claims Adjudicator facilitates the claims adjudication process through effective claims
management. The incumbent will ensure claim accuracy, bill payors, and coordinate with the Copay Assistance Department as necessary.

Duties and Responsibilities

• Claims analysis (cost of goods, total allowed amount, portion paid by the insurance, patient’s copay)
• Test claim refill orders
• Troubleshoot claim rejections
• Bill primary and secondary payors
• Review coverage of primary and secondary payors
• Coordinate with Copay Assistance Department when copay funds are depleted to obtain additional funds
• Coordinate with the Patient Care Coordinator Supervisor the order claim status if there is a delay in scheduling
• Identify and add new payors when the patient’s insurance has changed
• Ensure accuracy of NCPDP claim submission
• Review order profitability
• Proper documentation of patient’s medication coverage in progress notes
• Ensure compliance with the 14-day window of adjudication and scheduled delivery
• Manage claims exception
• Reports underpaid claims, changes in reimbursement from previous claims, pricing issues, and billing or copay assistance issues to supervisor

Required Qualifications

• Well-organized and strong attention to detail
• NCPDP Claim Submission Experience
• High School diploma or equivalency

Preferred Qualifications

• Prior authorization/override experience preferred
• CPR+ experience preferred

AmeriPharma’s Mission Statement

Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!

Physical Requirements

The following physical activities described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions and expectations

EEO Statement

The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required. The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time. AmeriPharma values diversity in its workforce and is proud to be an AAP/EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or on the basis of disability or any other legally protected class.