CVS Health Adjudication Specialist I in Sanford, Florida

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Billing Specialist I will be responsible for qualifying, preparing and submitting claims to Medicare Part B and Medicaid. Individual must work with long term care facility staff, Omnicare pharmacy operations staff, prescriber offices, third party payers, patients and/or their responsible parties and claim processors. This position requires work within several different pharmacy dispensing systems and web based billing portals and software programs. Billers must obtain supporting clinical and non-clinical information to perform coverage criteria review. Billers must verify valid dispensing orders for all new and refill orders and work claims through to resolution to ensure compliant, timely and accurate billing.


  • Responsible for all Part B covered drug and Medicaid supply billing for Omnicare Manage assigned queues keeping up to date and current on all point of sale claims

  • Review and research rejected third party claims taking appropriate actions to resolve

  • Contact facility, beneficiary and/or prescribers to obtain all clinical and non-clinical information needed to perform coverage criteria review

  • Verify preliminary dispensing orders are valid for all new and refill orders and that the information is accurate on the third party claim. Work with pharmacy or facility to correct errors or rectify issues prior to dispensing

  • Assist other adjudication departments with coverage criteria review

  • Obtain and maintain all documentation required by CMS to support claim billing

  • Identify, compile and send all documentation necessary to respond to CMS pre and post payment audits

  • Point of contact to assist internal and external customers with inquiries related to specialized Medicare Part B and/or Medicaid supply billing

  • Process and submit overpayment refund requests and on account credits as needed

  • Generate and work a variety of quality assurance reports

  • Work backlog of rejected claims for timely resubmission

  • Must meet monthly call volume, billing accuracy and productivity metrics

  • Routinely monitor pharmacy dispensing and intake functions to identify any issues and bring to the attention of supervisor for continued process improvement considerations

  • Identify NDC /manufacturer coverage issues and/or product setup issues and work with applicable designees to resolve

  • Follow all applicable government regulations including HIPAA

  • Employee is required to work the days and hours scheduled by immediate supervisor; subject to change due to business needs. Overtime may be required

  • All other duties as assigned


Minimum (Required) Qualifications: (must be met in order to perform the job at the required level)

  • High school diploma or equivalent

  • Strong verbal and written communication, interpersonal, and prioritization skills

  • Must be highly organized and detail-oriented

  • Ability to work in a fast paced, rapidly changing environment

  • Requires the ability to exercise independent judgment and employ basic reasoning skills.

  • Good computer skills requiring basic knowledge of Microsoft Word, Excel, PowerPoint, Outlook and good typing skills with minimal errors

  • Demonstrate high level of integrity and professionalism to handle sensitive and confidential information

  • Ability to perform basic mathematical calculations

  • Ability to work both independently and as part of a team

Preferred Qualifications: (if above and beyond the minimum required)

  • Prior experience in medical billing

  • Basic knowledge of pharmacy operations

Hours: 10am-6pm

ADA Compliance:

Work in a climate-controlled, smoke-free internal environment. May sit seven (7) to ten (10) hours per day. May stand, stoop, bend and walk intermittently during the day. May be necessary to work extended hours as needed. Finger dexterity to operate office equipment required. May need to lift up to twenty-five (25) pounds on occasion. Visual acuity to see and read fine prints. Specific vision abilities required by this job include close vision, color vision and the ability to adjust focus. Must be able to hear normal voice sounds.

Equal Opportunity Employer: Omnicare is fully committed to employing a diverse workforce. We recruit and retain talented individuals without regard to gender, race, age, marital status, disability, veteran status, sexual orientation and gender identity or any other status protected by federal, state or local law. Omnicare is an Equal Employment Opportunity and Affirmative Action Employer.


Business Overview

Omnicare, Inc. is a wholly owned subsidiary of CVS Health Corporation.

What We Do

Directly, and through our subsidiaries, Omnicare provides a broad array of pharmacy-related services to long term care facilities and to other customers in the health care environment. While senior care has long been an Omnicare specialty, we also serve other targeted populations.

Commitment at Every Level

A large part of Omnicare's success derives from a commitment, at every level, to the welfare of each individual we serve. Each day, our employees consider how their work can improve the quality of life of residents and patients. Omnicare is truly a health care company, working to improve the health and quality of life for everyone we touch.

Requisition ID 2016-21970

Position Type Regular Full-Time

Job Locations US - FL - Sanford

Division LTC

Category Billing