Pharmacy Adjudication Specialist

CommuniCare Health Services

Adjudication Specialist managing real time insurance claims while providing customer service to clients. Ensuring compliance with federal and state regulations for CommuniCare Family of Companies.

Posted 5/31/2026full-timeRemote • Maryland, Ohio, Virginia, West Virginia • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Manage real time insurance claims while providing customer service to clients
Analyze and approve claims that need to be adjudicated
Determine coverage and apply medical necessity guidelines
Identify and clarify any discrepancies to complete the adjudication process
Work in cohesion with the CIC Department, Prior Authorization, and Billing Departments
Submit claims and add appropriate corrections
Ensure accurate and timely processing of real time claims
Work directly with third party payers for claim resolution
Communicate with facilities on claim issues that will need attention by the facility
Resolve any discrepancies and secure proper reimbursement
Any other duties associated with adjudication
Create Prior Authorizations and notify Authorization team
Follow federal and state regulations
Adhere to company policies and procedures
Follow HIPPA guidelines and regulations

Requirements

What you’ll need

Pharmacy Technician License in Ohio, West Virginia, Indiana, and Maryland (All is preferred, but not required)
Previous Long-Term Care pharmacy experience a plus (but not required)
Knowledge of Framework LTC a plus (but not required)

Benefits

Comp & perks

Comprehensive benefits package, including health, dental, and vision insurance
401(k) with company match
Paid time off

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims managementclaims adjudicationmedical necessity guidelinesdiscrepancy resolutionprior authorizationstimely processingreimbursementHIPAA complianceinsurance analysis

Soft Skills

customer servicecommunicationcollaborationattention to detail

Certifications

Pharmacy Technician License