Adjudication Specialist - Remote

WHO WE ARE
At Polaris Pharmacy Services, we’re more than a pharmacy — we’re a dedicated partner in care, transforming how patients experience long-term, post-acute, correctional, PACE, and specialty pharmacy services. As industry leaders, we’re raising the bar for quality and coordination across all sites of care, ensuring every patient receives seamless, compassionate, and expert support.

Founded in 2015, Polaris is proud to be locally and independently owned, with a growing national footprint. Our team thrives in a mission-driven environment where innovation meets purpose, and every role contributes to making a real impact. We offer more than just a job — we provide competitive pay, robust benefits, and genuine opportunities for career advancement.

If you're passionate about shaping the future of pharmacy and making a difference in the lives of those who need it most, we invite you to grow with us.

JOB SUMMARY:

The Adjudication Specialist manages a portfolio of rejected pharmacy claims, ensuring timely billing and maximum payer reimbursement. They prioritize customer needs, maintain courteous communication, and build effective relationships with colleagues and clients. Their goal is to uphold customer trust and enhance our services.

DUTIES/RESPONSIBILITIES:

• Manage and Identify Claims Portfolio:
  • Review and evaluate insurance claims to determine the extent of the insurer’s liability, adhering to policy provisions and state and federal regulations.
  • Authenticate claimants and verify the accuracy of claim submission documents to prevent fraud and ensure compliance with policy terms.
• Resolve Rejected Claims:
• Calculate benefit payments and approve claim settlements based on policy coverage and assessment findings.
• Coordinate with healthcare providers, repair services, or other parties to obtain additional documentation necessary for claim resolution.
• Effective Communication and Risk Management:
• Negotiate settlements with claimants or their representatives in cases of disputed claims.
• Monitor and resolve revenue risks associated with payer setup, billing, rebilling, and reversal processes.
• Policy Interpretation and Compliance:
• Interpret and apply complex insurance policy language to diverse claim scenarios.
• Provide detailed explanations to claimants regarding the adjudication process, claim denials, or settlement offers
•  Additional Responsibilities:
• Implement alternative dispute resolution methods when conventional negotiation does not achieve a settlement.
• Complete necessary payer paperwork, including prior authorization forms and manual billing.
• Handle non-standard order entry situations as required.
• Support training needs within the team.
• Duties may vary depending on business needs and operational context.