Claims Adjudicator

Job Summary

The Claims Adjudicator facilitates the claims adjudication process through effective claims
management. The incumbent will ensure claim accuracy, bill payors, and coordinate with the Copay Assistance Department as necessary.

Duties and Responsibilities

Claims analysis (cost of goods, total allowed amount, portion paid by the insurance, patient’s copay)

Test claim refill orders

Troubleshoot claim rejections

Bill primary and secondary payors

Review coverage of primary and secondary payors

Coordinate with Copay Assistance Department when copay funds are depleted to obtain additional funds

Coordinate with the Patient Care Coordinator Supervisor the order claim status if there is a delay in scheduling

Identify and add new payors when the patient’s insurance has changed

Ensure accuracy of NCPDP claim submission

Review order profitability

Proper documentation of patient’s medication coverage in progress notes

Ensure compliance with the 14-day window of adjudication and scheduled delivery

Manage claims exception

Reports underpaid claims, changes in reimbursement from previous claims, pricing issues, and billing or copay assistance issues to supervisor

Required Qualifications

Well-organized and strong attention to detail

NCPDP Claim Submission Experience

High School diploma or equivalency

Preferred Qualifications

Prior authorization/override experience preferred

CPR+ experience preferred