MAC Appeals Specialist

MAC Appeals Specialist Hot Job Fully Remote • Polaris Pharmacy Services of Ft Lauderdale - Ft. Lauderdale, FL 33309 Apply Overview Position Type Full Time Category Admin - Clerical Apply Description 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: This role owns our Maximum Allowable Cost (MAC) and under reimbursement appeal process: identifying claims reimbursed below acquisition cost, building supporting documentation, and submitting timely appeals to PBMs to recover fair payment. This position requires sharp attention to detail, strong recordkeeping discipline, and confident, professional communication with PBM auditors and provider relations teams. DUTIES/RESPONSIBILITIES: MAC Appeals & Reimbursement Recovery Monitor claims adjudication data to identify claims reimbursed below the pharmacy's acquisition cost or NADAC due to Maximum Allowable Cost (MAC) pricing. Compile MAC appeal packages, including current wholesaler invoices, NDCs, and evidence of drug unavailability at the listed MAC price. Submit timely, well-documented MAC appeals to PBMs in accordance with each payer's required format and appeal window. Track the status of all submitted appeals, follow up on outstanding requests, and escalate denied or unresolved appeals as needed. Analyze appeal outcomes and reimbursement trends to flag drugs/NDCs with chronic underpayment issues for ongoing appeal or formulary discussion. Communicate directly with PBM provider relations and pricing teams to resolve disputes and confirm MAC list pricing updates once appeals are substantiated. Report reimbursement recovery results, denial trends, and outstanding audit risk to pharmacy leadership on a regular basis. Assist PBM and payer audit team in the collection of data such as hard-copy prescriptions, signature logs, proof-of-delivery records, wholesaler invoices, and inventory records — within each PBM's mandated turnaround time. Stay current on each PBM's provider manual, network agreement terms, and audit appeal procedures and deadlines. Qualifications QUALIFICATIONS/COMPETENCIES: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. REQUIRED SKILLS/ABILITIES: Required High school diploma or GED required; Associate’s or Bachelor’s degree in a related field preferred. Certified Pharmacy Technician (CPhT) license/certification preferred. Working knowledge of NDC, NCPDP claim formats/rejection codes, and pharmacy claims adjudication processes. Familiarity with MAC pricing, AWP/WAC benchmarks, and how PBM reimbursement and audit programs work from the pharmacy's side. Comfort working with claims data in Excel. Excellent written and verbal communication skills, including the ability to build a clear, well-supported case in an audit rebuttal or MAC appeal. Highly organized and detail-oriented, with the ability to manage multiple audits, appeals, and deadlines across several PBM contracts at once. Preferred Prior experience specifically handling MAC appeals on behalf of a pharmacy. Knowledge of state MAC transparency and appeals legislation, and pharmacy audit integrity laws (e.g., restrictions on extrapolation, recoupment timelines). Experience working with pharmacy trade associations or third-party reimbursement consultants. PHYSICAL DEMANDS The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job: May sit or stand seven (7) to ten (10) hours per day The employee is occasionally required to sit; climb or balance; and stoop, kneel, bend, walk May be necessary to work extended hours as needed May lift and/or move up to 30 pounds The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this role HOLIDAY & PTO POLICY Paid holidays are provided annually, with 6 days offered each year, along with 5 sick days. Employees earn up to 10 PTO days each year, with rollover options and milestone bonuses. Employees have the option to cash out up to 10 PTO hours each quarter for added financial flexibility. Please note, because we are a pharmacy most of our locations are open 24-hours a day, 7 days a week and therefore schedules may change as determined by the needs of the business. BENEFITS for full time Employees Medical, Dental, and Vision insurance 401 (k) (available for Part Time & Full Time EEs) Company Paid Life insurance Short-term and Long-term disability insurance Tuition reimbursement Personal Time Off (PTO) Competitive pay with annual performance reviews and merit-based raises Career growth potential Annual on-site voluntary Flu Vaccines Employee referral bonus program