Pharmacy Adjudication Specialist

Job Address: 9299 Market Place Broadview Heights, OH 44147 Job Title: Claim Adjudication Department Specialist Reports to: Adjudication Specialist Supervisor Job Type: Full-Time – Remote – Pharmacies located in: West Virginia, Ohio, Indiana, and Maryland Position Overview: As the Adjudication Specialist, you will manage real time insurance claims, while providing customer service to clients. Analyze and approve claims that need to be adjudicated. Determine coverage and apply medical necessity guidelines. Identify and clarify any discrepancies to complete the adjudication process. Key Responsibilities Include but are not limited to: Work in cohesion with the CIC Department, Prior Authorization, and Billing Departments Submit claims and add appropriate corrections Ensure accurate and timely processing of real time 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 Any other duties associated with adjudication Create Prior Authorizations and notify Authorization team Follow federal and state regulations Adhere to company policies and procedures Follow HIPPA guidelines and regulations Qualifications and Requirements: Pharmacy Technician License in Ohio, West Virgina, Indiana, and Maryland (All is preferred, but not 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 Since 1984, CommuniCare Family of Companies has been committed to delivering exceptional person-centered care as a national leader in post-acute care for those that are chronically ill or have complex conditions. Our more than 150 skilled nursing, assisted living, and long-term care facilities deliver sophisticated and transformative care to nearly 16,000 residents and patients at any given time. CommuniCare employs more than 19,000 employees across six states (Ohio, Indiana, Maryland, Virginia, West Virginia and Pennsylvania). As a family owned and operated company, family and heart are woven into every aspect of our continuum of care. Our mission, to serve with pride, is evident and a quality residents, families and community partners have come to expect and trust. Dedicated to improving the lives of seniors, we put extraordinary service above all else. We continue to raise the bar and innovate wherever possible to deliver a higher quality of life for those far beyond our facilities. Because of this, our facilities are a better place for residents to live, patients to stay, employees to work and families to heal.