LTC Pharmacy Adjudication Specialist *AM SHIFT - ROTATING WEEKENDS AND HOLIDAYS*

Hours for this role are 7AM-3:30PM CST with rotating weekends

Job Summary

The Adjudication Specialist is responsible for submitting and adjudicating third-party prescription claims in real time and resolving claim rejections or issues that impact timely billing and delivery of medications to long-term care (LTC) facilities. This role focuses on accurate claim processing, timely follow-up on denials and prior authorizations, effective communication with facilities, authorized representatives, and payers, and adherence to established policies, procedures, and payer requirements. The Adjudication Specialist plays a critical role in supporting revenue integrity, minimizing write-offs, and ensuring uninterrupted patient care.

Education \& Experience Requirements

· High school diploma or equivalent required.

· Prior experience in pharmacy adjudication, billing, or healthcare revenue cycle preferred.

· Long-term care pharmacy experience strongly preferred.

· Current State Pharmacy Technician license required.

· Experience with FrameworkLTC preferred.

· Strong attention to detail and accuracy.

· Effective analytical and problem-solving skills.

· Ability to manage multiple priorities in a fast-paced environment.

· Strong written and verbal communication skills.

· Professional, customer-focused demeanor.

· Ability to work independently and collaboratively.

Essential Job Functions

Claim Processing \& Adjudication

· Review, submit, and adjudicate third-party prescription claims accurately and efficiently in real time.

· Identify, troubleshoot, and resolve denied or rejected claims in a timely manner which may include outbound calls for resolution.

· Work claims in accordance with established timelines, payer rules, and internal policies and procedures.

· Initiate prior authorizations as required based on claim rejections, payer requirements, or medication criteria.

· Follow up on pending prior authorizations with prescribers, facilities, and third-party payers to ensure timely resolution.

· Rebill rejected or reversed claims throughout the shift as scheduled.

· Run and work assigned reports, including Negative Margin Reports and other daily adjudication-related reports, as directed.

· Provide facility price quotes as requested by staff at LTC facilities

· Process new admissions throughout the day, verifying payer status to accurately determine medication quantities and appropriate days’ supply.

· Any and all other duties as assigned by leadership team.

Communication \& Documentation

· Communicate professionally and effectively with facility staff, residents, authorized representatives, powers of attorney, third-party payers, prescribers, and internal team members.

· Correspond with designated facility staff regarding high-dollar medication approvals, prior authorizations, and adjudication-related issues.

· Provide clear and timely updates to customers regarding claim status, delays in sending medications, prior authorization status.

· Create and distribute communication memos regarding billing or adjudication issues to facility management and nursing staff when required.

· Document claim activity, prior authorization status, payer communications, and facility-specific requirements accurately for follow-up and audit purposes.

· Update reference materials as needed and share payer rule changes with teammates and management.

Workflow Support \& Prioritization

· Work according to facility delivery schedules and prioritize claims to support on-time medication delivery.

· Support preparation and expediting of STAT and urgent deliveries.

· Assist other team members to maintain workflow and department productivity.

· Demonstrate strong time-management, multitasking, and communication skills to effectively collaborate with team members, maintain workflow efficiency, and meet delivery deadlines.

Compliance \& Professional Standards

· Follow established guidelines, payer-specific requirements, and facility-specific billing instructions.

· Maintain an active State Pharmacy Technician license in good standing.

· Obtain PTCB or ExCPT certification within 12 months of hire if newly licensed; ensure timely renewals if certified.

· Adhere to all company’s policies, procedures, and code of conduct.

Job Type: Full-time

Pay: $21\.89 - $27\.04 per hour

Benefits:

• 401(k)
• Health insurance
• Paid time off

Work Location: Remote