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Role Description

The LTC Pharmacy Adjudicator is responsible for communicating to the communities when order exceptions occur such as non-formulary, expensive medications, and incomplete orders. This position works closely with the community staff to have orders clarified and medications changed to less expensive alternatives. Coordinates all adjudication on Medicare D claims where needed and performs all functions required to maintain, update, and bill customers’ accounts timely and accurately.

Working Schedule:

• 12:00pm-8:30PM Monday-Friday
• Occasionally, 2:30PM-11:00PM
• Every other weekend
• Must work rotating holidays
• 100% Remote

Must currently live in a state Symbria Rx Services is licensed in: AZ, CO, FL, IL, IN, KS, MA, MI, MO, PA, OH, WI.

Internet Requirements:

• High-speed internet access provided by a cable or fiber provider (no DSL or satellite)
• Minimum connection speed of 50 Mbps for downloads and 10 Mbps for uploads (for three local devices)
• Minimum connection speed of 75 Mbps for downloads and 10 Mbps for uploads (for four or more devices)
• Latency must be below 35
• Wire connection to home internet router is recommended
• Wi-Fi ‘air cards’ (mobile hot spots) are prohibited as your main internet connection

Responsibilities

• Initiate communication to communities regarding expensive and non-formulary medication orders and educate on less expensive alternatives identified by staff pharmacists.
• Initiate communication to community regarding incomplete orders which require further clarification.
• Keep detailed records of all orders that require communication to the community for potential follow up if needed.
• Follow up with the community per policy timeframe if the medications have not been changed or clarified. Send another supply of medication if needed.
• Communicate professionally with community management staff including Director of Nursing and Administrator via phone or email.
• Assist with data entry of orders as needed.
• Assist with answering phone calls for the data entry department.
• Review Medicare D rejections and prior authorizations, and coordinate with pharmacists or physicians to successfully adjudicate all claims.
• Work in conjunction with designated operations staff to prepare for formulary changes.
• Perform insurance and billing clerical duties, including review and maintenance of patient account information.
• Prepare and submit claims to various third parties either electronically or by paper.
• Identify and resolve claim denials.
• Act as liaison between patients and third parties.
• Work collaboratively with other team members and supervisor to ensure best practices are shared.
• Provide backup support to other pharmacy departments based on business needs or production levels, as needed.
• Any and all duties as assigned.

Qualifications

• High School diploma or general education degree (GED).
• Pharmacy Technician License and/or Certification (CPhT) as per State requirements (must be licensed in Illinois and Massachusetts within 60 days of hire).
• Data entry experience; minimum one year.
• Excellent customer service, interpersonal, verbal and written communication skills.
• General computer knowledge including Microsoft Office: Word, Excel, and Outlook.
• Ability to maintain organization, multi-task and prioritize to manage assignments/projects.
• Strong knowledge of Brand/Generic drugs and medical terminology.

Benefits

• Competitive pay, aligned with market guidelines
• Full Benefits Package, including very generous paid time off plans
• Professional liability coverage
• 100% employer-funded ESOP retirement plan
• 401(k) and Roth(k) plans
• Continuing education
• Credit union membership