Pharmacy Adjudication Associate

Title: Pharmacy Adjudication Associate

Dept: Billing and Reimbursement

Reports To: Adjudication Manager

Location: Remote

Shift: 2nd Shift 4PM - 12:30PM (With Shift Differential)

Position Summary

The primary goal of the Clarest Pharmacy Adjudication Associate is to understand and utilize all processes associated with adjudicated rejected claims, system alerts and other communications. The Adjudication Associate is responsible for working with each of our pharmacy locations to provide resolution or added information needed to assure payment before each scheduled pharmacy delivery cutoff. This function is directly interfaced with the pharmacy workflow for fulfillment and distribution of medications and as a result, timeliness and accuracy are paramount.

Essential Functions – primary position responsibilities:

• Work rejections to the farthest possible outcome before triaging issue to other billing teams.
• Work refill too soon rejections appropriately
• Create detailed, accurate forms for non-covered medications and communicate these forms to the appropriate recipients (internal and external)
• Adhere to the departmental processes associated with the documentation and review of claims processing.
• Provide proper notation on prescriptions in the document server as well as in the billing comment sections of prescriptions.
• Triage documents correctly in the document server
• Ensure timely input of information into our pharmacy fulfillment software based on information to assure on-time fulfillment of prescription to the patient.
• Communicate efficiently and effectively with team members, pharmacists, nursing facility staff and insurance companies.
• Research system for member eligibility. Create and record patient and insurance information.
• Escalate issues pertaining to workflow to Adjudication Leadership.
• Respond to Adjudication related emails in a timely manner.
• The ability to adhere to Clarest’s Code of Conduct, follow Clarest Compliance policies and procedures, and report any suspected violations of any federal or state laws to either their direct supervisor, Human Resources, or the Compliance Officer
• Any and other responsibilities as assigned by the manager to support these and other responsibilities in the department.

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of this employee for this role.

Required Skills (Education/Certification/ Licenses/Years of Experience):

• High school diploma or equivalent, required.
• Knowledge of Medicare Part D, Medicaid, and Commercial insurances, required.

• Intermediate knowledge of Microsoft Outlook, and Teams, required.
• Intermediate experience with Framework LTC and DocuTrack preferred.
• Ability to maintain confidentiality including but not limited to HIPPA.

Competencies:

• Critical thinking and problem-solving skills, required.
• Ability to multi-task and prioritize in a fast-paced environment.
• Ability to review employees work and provide comments, feedback, and coaching.
• Courteous, empathic, and professional demeanor, a team player.
• Strong communication, interpersonal, and organizational skills.
• Receptive to feedback, willing to learn, embracing continuous improvement.

Supervisory Responsibility: None

Budget Responsibility: None

Describe the nature and scope of independent decisions made in this position:

Ability to evaluate process path based off information obtained from insurance or another payer. Responsible for managing queue of workload and reporting any concerns to leadership.

Work Environment:

This job is performed remotely and requires a dedicated, secure workspace where PHI cannot be easily accessed. Hardwired high-speed internet is required, no Wi-Fi.

All equipment will be supplied by the employer. (Computer, keyboard, mouse, monitors, audio/video, etc.)

Physical Demands: Deskwork, sitting for long periods, extended periods of screen time, and phones. No heavy lifting is required.

Position Type/Expected Hours: The role is a full-time, hourly rate, 40-hour-per-week rotating schedule with rotating weekends.

Travel (if yes, percentage of travel time required): None

Other unique responsibilities or conditions not previously addressed (driver’s license, bilingual, etc.): None

Clarest is an Equal Opportunity Employer. Reasonable accommodations will be made to enable individuals with disabilities to apply for a job or to perform the essential functions of their job. Please advise us if you require a reasonable accommodation.