Pharmacy Billing and Adjudication Specialist

ESSENTIAL JOB FUNCTIONS: (include the following):Research and establish patient eligibility coverage with insurance providers including private individuals and/or government entities. Reverify benefit coverage criteria as needed for claims follow up. Accurately enters and/or updates patient/insurance information into billing system. Maintain and continually audit patient files and corresponding documentation necessary to defend third party audits and ensure payer and company compliance. Accurately enter patient information into the pharmacy system. Provide assistance and timely response to all billing customer inquiries via phone or electronic communications. Research and resolve patient billing issues regarding insurance eligibility, coverage, and related benefits. Provide guidance and support to resident or responsible party by running Medicare plan comparisons during open enrollment and special enrollment periods. Proactively review patient profiles, drug regimens and insurance coverage to evaluate options to save resident money. Responsible for completion of daily census, admit, discharge, and room changes for the facilities assigned. Process patient payments, returns, and credits. Transmit individual credit card payments as needed. May pursue payment from delinquent accounts and make payment arrangements. Research, identify and organize requested audit documentation in timely manner. Perform prescription claims adjudication including communication with insurance companies regarding rejected claims, eligibility, prior authorizations or other issues as needed. Make corrections as needed and rebill claims as necessary. Develop knowledge and understanding in pharmacy facility billing requirements (Medicare, Medicaid, Prescription Drug Plans (PDPs) and Third-Party Insurances) Develop proficiency in the utilization of pharmacy information systems to meet operational needs and regulatory requirements. This includes using pharmacy systems to process prior authorizations, resolve rejections, produce various reports as necessary, and complete billing functions. Rotate through other departments to gain working/functional knowledge of other department workflows. Follow all applicable government regulations including HIPAA.Work as a collaborative team member to meet the service goals of the pharmacy. Other essential functions and duties may be assigned as needed. EDUCATION AND/OR CERTIFICATIONS:High School Diploma or GED required. Pharmacy Technician license/certification/registration per state requirements; National Certification preferred (PTCB) may be required (pharmacy specific).

SKILLS AND QUALIFICATIONS: 1+ years of related experience

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the job. The noise level in the work environment is usually low to moderate. Due to the collaborative nature of the business and the need to service customers, the employee must be able to interact effectively with others in an office environment, manage conflict, and handle stressful situations and deadlines. Requires desk work in office environment. Ability to work flexible hours.