Claims Adjudicator

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