Claims Adjudicator

About AmeriPharma

AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.

AmeriPharma’s Benefits

• Full benefits package including medical, dental, vision, and life
• Great pay and general compensation structures
• Employee assistance program to assist with mental health, legal questions, financial counseling, etc.
• Comprehensive PTO and sick leave options
• 401k and matching programs
• Plenty of opportunities for growth and advancement
• Company sponsored outings and team-building events
• Casual Fridays

Job Summary

The Claims Adjudicator is responsible for overseeing the claims adjudication process through effective management of claims. This role ensures the accuracy and timely processing of claims, coordinates bill payments, and collaborates with the Copay Assistance Department as needed to resolve issues.

Schedule Details
Location: On-Site (Laguna Hills, CA)
Hours: Monday-Friday,  9:00 AM - 5:30 PM

Duties and Responsibilities

• Collaborate closely with pharmacists and other departments to ensure seamless claims processing.
• Perform thorough reconciliation of daily batch postings to ensure all transactions are accurately recorded and balanced. 
  
• Manage both automated and manual batch posting processes, including the accurate input and verification of claims and payment
  
• Stay informed on current billing issues and implement necessary changes to existing billing practices.
• Maintain comprehensive knowledge of prescription plans and their intricacies.
• Analyze claims, considering factors such as the cost of goods, allowed amounts, insurance coverage, and patient copays.
• Troubleshoot and resolve claim rejections and overrides as necessary.
• Use decision trees to assess whether a case will be serviced or transferred to another department.
• Process claims for both primary and secondary payers.
• Review patient coverage for primary and secondary payers and determine eligibility for copay assistance or enrollment in FHP.
• Coordinate with the Financial Assistance Department to secure additional funding when copay assistance is exhausted.
• Work with the Patient Care Coordinator Supervisor to address delays in claim scheduling and order statuses.
• Update insurance information and add new payors when patients experience insurance changes.
• Ensure accuracy in NCPDP claim submissions.
• Review order profitability and manage the 3 & 5 queues to complete margin reviews and update last events.
• Oversee the B queue, test claim refill orders, and update last events.
• Manage the 541 queue, confirming delivery tickets and resolving rejected claims.
• Accurately document patient medication coverage in progress notes.
• Adhere to the 14-day adjudication and scheduled delivery window.
• Promptly report underpaid claims, reimbursement changes, pricing issues, or billing/cost assistance issues to the supervisor.
• Perform other duties as assigned.

Required Qualifications

• Previous pharmacy experience
• Strong interpersonal skills with the ability to collaborate effectively
• Excellent verbal and written communication skills
• Ability to work independently and manage multiple deadlines in a fast-paced environment
• Strong organizational skills and keen attention to detail
• Proficient typing and keyboarding skills
• Fluency in reading, writing, speaking, and understanding English

Preferred Qualifications

• Experience with prior authorization/override processing
• Familiarity with CPR+ software

AmeriPharma’s Mission Statement 

Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!

Physical Requirements 

The following physical activities described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions and expectations

EEO Statement 

The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required. The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time. AmeriPharma values diversity in its workforce and is proud to be an AAP/EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or on the basis of disability or any other legally protected class.