Pharmacy Adjudication Jobs in Reston, VA (NOW HIRING)

Extraordinary Care. Extraordinary Careers.

With one of the nation's largest, most innovative long-term care pharmacy services providers, there is no limit to the growth of your career.

Southern Pharmacy Services, a member of the Guardian family of pharmacies, has an exciting opportunity for you to join our rapidly growing team in Gainesville, Virginia.

Why Southern Pharmacy Services? We're reimagining medication management and transforming care.

Who We Are and What We're About:

Our core focus is delivering customized medication management solutions to support healthcare organizations serving seniors and individuals with complex care needs. With our comprehensive suite of tech-enabled pharmacy services and a dedicated team of professionals committed to enriching the lives of those we serve, we are redefining how pharmacy care is delivered.

We offer an opportunity to learn and grow your career in a fast-paced, diverse, and inclusive environment. If you are looking for a challenging, team-oriented environment in which you can put your expertise to work, then this is the place for you.

Responsible for processing customer bills and insurance claims in an accurate and timely manner. This includes assisting with all daily and month-end billing functions, procedures and reporting. Provides excellent customer service to patients, caregivers, medical providers and insurance carriers.

Schedule Needed:

Monday - Friday Open availability required between hours of 7:30am-8pm.

Rotating weekend schedule.

ATTRIBUTES REQUIRED:

• Work Ethic/Integrity - must possess intrinsic drive to excel coupled with values in line with company philosophy
• Relational - ability to build relationships with business unit management and become "trusted advisor."
• Strategy and Planning - ability to think ahead, plan and manage time efficiently.
• Problem Solving - ability to analyze causes and solve problems at functional level.
• Team Oriented - ability to work effectively and collaboratively with all team members.

ESSENTIAL JOB FUNCTIONS (include the following):

• Research and establish patient eligibility coverage with insurance providers including private individuals and/or government entities. Reverify benefit coverage criteria as needed for claims follow up. Accurately enters and/or updates patient/insurance information into billing system.
• Maintain and continually audit patient files and corresponding documentation necessary to defend third party audits and ensure payer and company compliance. Accurately enter patient information into the pharmacy system.
• Provide assistance and timely response to all billing customer inquiries via phone or electronic communications. Research and resolve patient billing issues regarding insurance eligibility, coverage, and related benefits.
• Provide guidance and support to resident or responsible party by running Medicare plan comparisons during open enrollment and special enrollment periods. Proactively review patient profiles, drug regimens and insurance coverage to evaluate options to save resident money.
• Responsible for completion of daily census, admit, discharge, and room changes for the facilities assigned.
• Process patient payments, returns, and credits. Transmit individual credit card payments as needed.
• May pursue payment from delinquent accounts and make payment arrangements.
• Research, identify and organize requested audit documentation in timely manner.
• Perform prescription claims adjudication including communication with insurance companies regarding rejected claims, eligibility, prior authorizations or other issues as needed. Make corrections as needed and rebill claims as necessary.
• Develop knowledge and understanding in pharmacy facility billing requirements (Medicare, Medicaid, Prescription Drug Plans (PDPs) and Third-Party Insurances)
• Develop proficiency in the utilization of pharmacy information systems to meet operational needs and regulatory requirements. This includes using pharmacy systems to process prior authorizations, resolve rejections, produce various reports as necessary, and complete billing functions.
• Rotate through other departments to gain working/functional knowledge of other department workflows.
• Follow all applicable government regulations including HIPAA.
• Work as a collaborative team member to meet the service goals of the pharmacy.
• Other essential functions and duties may be assigned as needed.

EDUCATION AND/OR CERTIFICATIONS:

• High School Diploma or GED required.
• Pharmacy Technician license/certification/registration per state requirements; National Certification preferred (PTCB) may be required (pharmacy specific).

SKILLS AND QUALIFICATIONS:

• 1+ years of related experience
• Advanced computer skills; pharmacy information system experience preferred.
• Ability to work independently and deliver to deadlines.
• Great attention to detail and accuracy
• Ability to excel in a fast-paced, team-oriented environment working on multiple tasks simultaneously, while adhering to strict deadlines
• Quality minded; motivated to seek out errors and inquire about inaccuracies.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the job.

• The noise level in the work environment is usually low to moderate.
• Due to the collaborative nature of the business and the need to service customers, the employee must be able to interact effectively with others in an office environment, manage conflict, and handle stressful situations and deadlines.
• Requires desk work in office environment.
• Ability to work flexible hours.

What We Offer:

Guardian provides employees with a comprehensive Total Rewards package, supporting our core value of, "Treat others as you would like to be treated."
Compensation & Financial

• Competitive pay
• 401(k) with company match

Family, Health & Insurance Benefits (Full-Time employees working 30+ hours/week only)

• Medical, Dental and Vision
• Health Savings Accounts and Flexible Spending Accounts
• Company-paid Basic Life and Accidental Death & Dismemberment
• Company-paid Long-Term Disability and optional Short-Term Disability
• Voluntary Employee and Dependent Life, Accident and Critical Illness
• Dependent Care Flexible Spending Accounts

Wellbeing

• Employee Assistance Program (EAP)
• Guardian Angels (Employee assistance fund)

Time Off

• Paid holidays and sick days
• Generous vacation benefits based on years of service

The Guardian Difference

Our clients require pharmacy services that aren't "cookie cutter." That's why every Guardian pharmacy is locally operated and empowered with the autonomy to tailor their business to meet their clients' needs.

Our corporate support offices, based in Atlanta, Ga., provide services such as human resources, business intelligence, legal, and marketing to promote the success of each Guardian location.

Regardless of your role at Guardian, your voice and talents matter. Because healthcare is an ever-changing industry, we encourage innovative thinking, intellectual curiosity, and diverse viewpoints to ensure we stay competitive in today's dynamic business environment.

At Guardian,we are dedicated to fostering and advancing a diverse and inclusive workforce.

Join us to discover what your best work truly looks like.