Claims Adjudicator

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    "jobOpeningName": "Claims Adjudicator",
    "departmentLabel": "Revenue Cycle",
    "employmentStatusLabel": "Full-Time"
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    "location": {
      "city": "Laguna Hills",
      "state": "California",
      "postalCode": "92653",
      "addressCountry": "United States"
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    "datePosted": "2026-03-12",
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    "description": "<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">About AmeriPharma</span></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">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.</span></p>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">AmeriPharma’s Benefits</span></p>\n<ul>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Full benefits package including medical, dental, vision, and life</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Great pay and general compensation structures</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Employee assistance program to assist with mental health, legal questions, financial counseling, etc.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Comprehensive PTO and sick leave options</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">401k and matching programs</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Plenty of opportunities for growth and advancement</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Company sponsored outings and team-building events</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Casual Fridays</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">Job Summary</span></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">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.</span></p>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">Schedule Details</span><br><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\"><span style=\"font-weight: bold\">Location</span>: On-Site (Laguna Hills, CA)</span><br><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\"><span style=\"font-weight: bold\">Hours</span>: Monday-Friday,  9:00 AM - 5:30 PM</span></p>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">Duties and Responsibilities</span></p>\n<ul>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Collaborate closely with pharmacists and other departments to ensure seamless claims processing.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Perform thorough reconciliation of daily batch postings to ensure all transactions are accurately recorded and balanced. </span><br></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Manage both automated and manual batch posting processes, including the accurate input and verification of claims and payment</span><br></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Stay informed on current billing issues and implement necessary changes to existing billing practices.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Maintain comprehensive knowledge of prescription plans and their intricacies.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Analyze claims, considering factors such as the cost of goods, allowed amounts, insurance coverage, and patient copays.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Troubleshoot and resolve claim rejections and overrides as necessary.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Use decision trees to assess whether a case will be serviced or transferred to another department.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Process claims for both primary and secondary payers.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Review patient coverage for primary and secondary payers and determine eligibility for copay assistance or enrollment in FHP.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Coordinate with the Financial Assistance Department to secure additional funding when copay assistance is exhausted.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Work with the Patient Care Coordinator Supervisor to address delays in claim scheduling and order statuses.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Update insurance information and add new payors when patients experience insurance changes.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Ensure accuracy in NCPDP claim submissions.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Review order profitability and manage the 3 &amp; 5 queues to complete margin reviews and update last events.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Oversee the B queue, test claim refill orders, and update last events.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Manage the 541 queue, confirming delivery tickets and resolving rejected claims.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Accurately document patient medication coverage in progress notes.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Adhere to the 14-day adjudication and scheduled delivery window.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Promptly report underpaid claims, reimbursement changes, pricing issues, or billing/cost assistance issues to the supervisor.</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Perform other duties as assigned.</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">Required Qualifications</span></p>\n<ul>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Previous pharmacy experience</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Strong interpersonal skills with the ability to collaborate effectively</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Excellent verbal and written communication skills</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Ability to work independently and manage multiple deadlines in a fast-paced environment</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Strong organizational skills and keen attention to detail</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Proficient typing and keyboarding skills</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Fluency in reading, writing, speaking, and understanding English</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">Preferred Qualifications</span></p>\n<ul>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Experience with prior authorization/override processing</span></li>\n<li><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">Familiarity with CPR+ software</span></li>\n</ul>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">AmeriPharma’s Mission Statement </span></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">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!</span></p>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">Physical Requirements </span></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">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</span></p>\n<p><br></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt; font-weight: bold\">EEO Statement </span></p>\n<p><span style=\"font-family: tahoma, arial, helvetica, sans-serif; font-size: 12pt\">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.</span></p>",
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