Our Company
PharMerica
Overview
The Senior Director Adjudication will oversee the point-of-sale adjudication for 3rd party claim submission This individual will need to manage and coordinate all workflow processes and policies related to the adjudication of claims, monthly reporting, policies and procedures, revenue recognition, guide staff and report results to Senior Management.
This position is eligible to be remote (reside anywhere within the continental USA) with travel of approximately 25%
Responsibilities
Claim Adjudication:
- Responsible for overall management direction, and coordination of point-of-sale adjudication
- Ensure third party claims are resolved timely and accurately on a daily/monthly basis
- Develop and maintain a quality assurance process monitoring compliance in claim submission
- Develop and maintain Key Performance Indicators for claim accuracy and efficiency
- Communicates with payers, performs collections on advanced account portfolio, and is considered a subject matter expert on those account
- Work with multiple internal databases and reporting tools (Cloud docs, Cognos, Access, etc.)
- Print and key variances or write-offs for review by Team Lead and management to clear uncollectable revenue per guidelines of Sarbanes Oxley requirements and Signature Compliance guidelines
- When necessary, will rebill claims electronically in accordance with NCPDP standards, online through payer specific websites, manually through Universal Claim Forms, or through other approved methods for favorable resolution of denied claims or underpayments
- Report to management any issues that may result in uncollected revenue, including payers that are non-responsive or claims that are not successfully resolved after multiple attempts
- Consistently meets productivity metrics and performance standards
- Understands company pricing structure and general reimbursement allowances
- Stays up to date on third-party billing requirements and reimbursement guidelines
- Works with payers to understand specific reasons for recoups/repayments at different rate and measures to prevent future recoups
- Provide education to management and team members on payer specific claim processing rules, reimbursement, and other policy guidelines as gleaned by, and confirmed through working directly with payers
- Makes suggestions for improved cash reconciliation with various payers based on outcomes
- Responsible for escalating any issues to Senior Management
Policies and Procedures:
- Review and maintain updates for all relevant policies and procedures
- Analyze and write any new policies as needed
- Communicate all policy changes to effected parties as well as the Vice President of Revenue Cycle
- Oversee calculation and distribution of month end Key Performance Indicators for POS Adjudication
- Compile and distribute claim adjudication reporting package to all management
- Ad hoc reporting as requested
- Train staff on proper resolution of rejected claims
Other
- Other responsibilities as assigned
Qualifications
- Two-year degree or a minimum of three to five years’ work experience in Long Term Pharmacy
- Experience supervising/leading a team
- Knowledge of claim adjudication
- Knowledge of/experience working with provider billing
- Strong analytical acumen
- Strong leadership skills
- Excellent oral and written communication skills
- Minimal travel may be required
About our Line of Business
PharMerica is a full-service pharmacy solution providing value beyond medication. PharMerica is the long-term care pharmacy services provider of choice for senior living communities, skilled nursing facilities, public health organizations and post-acute care organizations. PharMerica is one of the nation’s largest pharmacy companies. PharMerica offers unmatched employee development, exceptional company culture, seemingly endless opportunities for advancement and the highest hiring goals in decades. For more information about PharMerica, please visit www.pharmerica.com. Follow us on Facebook, Twitter, and LinkedIn.
Salary Range
USD $180,000.00 – $210,000.00 / Year