Pharmacy Claims Specialist

Job Address:

Job Description: Claims Specialist

Reports to: Claim Specialist Supervisor

Job Type: Full Time, Fully Remote

Pharmacies: West Virginia, Ohio, Indiana and Maryland

Position Overview: As the Claims Specialist, you will manage the insurance claims process, while providing customer service to clients. Analyze and approve claims that cannot be adjudicated. Determines coverage and applies medical necessity guidelines. Identifies and clarifies any discrepancies to assist in the adjudication process.

Key Responsibilities Includes but is not limited to:

• Claim submissions and corrections

• Ensure accurate and timely processing of rejected claims

• Work directly with third party payers for claim resolution

• Communicate with facilities on claim issues that will need attention by the facility

• Resolve any discrepancies and secure proper reimbursement

• Will ensue that all items outlined in the Billing Manual- sub section Claims Specialist will be followed

• Collaborate with leadership teams to resolve denied claims

• Any other duties associated with post-adjudication

• Follow federal and state regulations

• Adhere to company policies and procedures

• Follow HIPPA guidelines and regulations

Qualifications and Requirements:

• Pharmacy Tech License (required)

• Previous Long-Term Care pharmacy experience a plus (but not required)

• Knowledge of Framework LTC a plus (but not required)

Salary and Benefits:

• Competitive salary commensurate with experience

• Comprehensive benefits package, including health, dental, and vision insurance, 401(k) with company match, paid time off, and more