LTC Pharmacy Adjudicator - Remote
Employment Type: Full-Time
The LTC Pharmacy Adjudicator is responsible for communicating to the communities when order exceptions occur such as non-formulary, expensive medications, and incomplete orders. This position works closely with the community staff to have orders clarified and medications changed to less expensive alternatives. Coordinates all adjudication on Medicare D claims where needed and to perform all functions required to maintain, update, and bill customers' accounts timely and accurately.
The hours of this position are 11AM-7:30PM, rotating weekends.
Must currently live in a state Symbria Rx Services is licensed in CO, IL, IN, MO, OH, PA, WI.
* Initiate communication to communities regarding expensive and non-formulary medication orders and educate on less expensive alternatives identified by staff pharmacists.• Initiate communication to community regarding incomplete orders which require further clarification.• Keep detailed records of all orders that require communication to the community for potential follow up if needed.• Follow up with the community per policy timeframe if the medications have not been changed or clarified. Send another supply of medication if needed.
* Communicate professionally with community management staff including Director of Nursing and Administrator via phone or email.• Assist with data entry of orders as needed.• Assist with answering phone calls for the data entry department.• Review Medicare D rejections and prior authorizations, and coordinate with pharmacists or physicians to successfully adjudicate all claims.• Work in conjunction with designated operations staff to prepare for formulary changes.• Perform insurance and billing clerical duties, including review and maintenance of patient account information.• Prepare and submit claims to various third parties either electronically or by paper.• Identify and resolve claim denials.• Act as liaison between patients and third parties.• Work collaboratively with other team members and supervisor to ensure best practices are shared.• Provide backup support to other pharmacy departments based on business needs or production levels, as needed.• Any and all duties as assigned.
To perform this job successfully, the ability to perform each essential duty satisfactorily is necessary and the qualifications listed below are representative of the knowledge, skill, and/or ability required:
* High School diploma or general education degree (GED).• Pharmacy Technician License and/or Certification (CPhT) as per State requirements.• Data entry experience; minimum one year.• Excellent customer service, interpersonal, verbal and written communication skills.• General computer knowledge including Microsoft Office: Word, Excel, and Outlook.• Ability to maintain organization, multi-task and prioritize to manage assignments/projects.• Strong knowledge of Brand/Generic drugs and medical terminology.
QUALIFICATIONS PREFERRED• Prescription billing experience; minimum one year.
* Long Term Care Pharmacy data entry experience.
* FrameWorks LTC experience strongly preferred.