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Medical Adjudication Jobs (NOW HIRING)

CareMed Specialty Pharmacy

$23/hr

Medical; Dental; Vision * 401k with a match * Paid Time Off and Paid Holidays * Tuition Reimbursement * Company paid benefits - life; and short and long-term disability Pharmacy Adjudication ...

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Medical Adjudication information

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$36.5K

$164.7K

$337K

How much do medical adjudication jobs pay per year?

As of Jun 23, 2026, the average yearly pay for medical adjudication in the United States is $164,731.00, according to ZipRecruiter salary data. Most workers in this role earn between $64,000.00 and $268,500.00 per year, depending on experience, location, and employer.

What does medical mean?

In the context of medical adjudication, 'medical' refers to matters related to health, healthcare services, and clinical assessments. Medical professionals review patient records, diagnoses, and treatment plans to determine insurance claims or benefits eligibility. Strong knowledge of medical terminology and documentation is essential for this role.

Does medical aid cover hair transplants?

Medical adjudicators evaluate insurance claims for procedures like hair transplants, but coverage depends on the specific medical aid plan and whether the procedure is deemed medically necessary. Generally, cosmetic hair transplants are not covered unless they are part of reconstructive surgery following injury or medical conditions. It is advisable to review the policy details or consult with the insurance provider for coverage specifics.

Is Medi-Cal the same as Medicaid?

Medical Adjudication professionals should know that Medi-Cal and Medicaid are related but not identical; Medi-Cal is California's Medicaid program, while Medicaid is a federal and state partnership providing health coverage across the U.S. Each state administers its own Medicaid program, which may have different names and coverage options. Understanding these differences is important when processing claims or verifying coverage for clients.

What's the maximum income to qualify for Medi-Cal?

For Medical Adjudication roles, eligibility for Medi-Cal generally depends on income levels relative to the Federal Poverty Level (FPL). As of 2023, most adults qualify if their income is at or below 138% of the FPL, which varies by household size. Specific income limits are updated annually and can differ based on the applicant's circumstances and program categories.

What is the difference between Medical Adjudication vs Medical Coding?

AspectMedical AdjudicationMedical Coding
Primary RoleReviewing and deciding insurance claim outcomes based on policy and medical documentationAssigning standardized codes to medical diagnoses and procedures for billing and record-keeping
Required CertificationsOften requires claims processing or adjudication certifications, knowledge of insurance policiesCertified Professional Coder (CPC), Certified Coding Specialist (CCS)
Work EnvironmentInsurance companies, healthcare providers, third-party payersHospitals, clinics, billing companies, insurance companies

Medical Adjudication involves evaluating insurance claims to determine coverage and payment, while Medical Coding focuses on translating medical services into codes for billing. Both roles require understanding healthcare documentation, but they serve different functions in the claims process.

More about Medical Adjudication jobs
What cities are hiring for Medical Adjudication jobs? Cities with the most Medical Adjudication job openings:
What states have the most Medical Adjudication jobs? States with the most job openings for Medical Adjudication jobs include:
What job categories do people searching Medical Adjudication jobs look for? The top searched job categories for Medical Adjudication jobs are:
Medical Adjudication jobs near you
Infographic showing various Medical Adjudication job openings in the United States as of June 2026, with employment types broken down into 2% As Needed, 82% Full Time, and 16% Part Time. Highlights an 81% Physical, 3% Hybrid, and 16% Remote job distribution, with an average salary of $164,731 per year, or $79.2 per hour.

Pharmacy Adjudication Specialist

Communicarehealth

Broadview Heights, OH • Remote

$22.50 - $31/hr

Full-time

Medical, Dental, Vision, Retirement, PTO

Posted 23 days ago

Job description

Job Address:

9299 Market Place Broadview Heights, OH 44147


Job Title: Claim Adjudication Department Specialist

Reports to: Adjudication Specialist Supervisor

Job Type: Full-Time - Remote - Pharmacies located in: West Virginia, Ohio, Indiana, and Maryland

Position Overview: As the Adjudication Specialist, you will 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.

Key Responsibilities Include but are not limited to:

  • 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

Qualifications and Requirements:

  • Pharmacy Technician License in Ohio, West Virgina, 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)

Salary and Benefits:

  • Competitive salary commensurate with experience
  • Comprehensive benefits package, including health, dental, and vision insurance, 401(k) with company match, paid time off, and more

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