Pharmacy Claims Adjudication Specialist

Job summary

The Pharmacy Adjudication Specialist is responsible for adjudicating pharmacy claims, resolving third-party rejections, and ensuring accurate coordination of benefits. They also serve as a liaison to patients and providers regarding financial responsibility and medication delivery status.

Job details

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy working in Mountain Time Zone. This will be a Full-Time position. This is a remote/hybrid opportunity, Shift times start at 10am Mountain Time Zone until 8pm Mountain Time Zone. Full-Time position may work remotely but MUST HAVE ACTIVE COLORADO PHARMACY TECHNICIAN credentials from the State Board of Pharmacy. Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers. Starting salary from $24.00 an hour and up Sign-On Bonus: $5,000 for employees starting before October 31st, 2026. We offer a variety of benefits including: * 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 Specialist Major Responsibilities: The Pharmacy Adjudication Specialist will adjudicate pharmacy claims, review claim responses for accuracy. ensure prescription claims are adjudicated correctly according to the coordination of benefits, resolve any third-party rejections, obtain overrides if appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections Pharmacy Adjudication Specialists at Onco360... * Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests. * Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information.. * Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information. * Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim. * Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications. Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays * Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible) * Manages all funding related adjudications and works as a liaison to Onco360 Advocate team. * Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment. * Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable. * Documenst and submit requests for Patient Refunds when appropriate. * Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws. * Contributes to team effort by accomplishing related tasks as needed and other duties as assigned. * Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards. Pharmacy Adjudication Specialist Qualifications and Responsibilities... * Education/Learning Experience * Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication * Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience * Work Experience * Required: 2+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience * Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience * Skills/Knowledge * Required: Pharmacy/NDC medication billing, Pharmacy claims resolution, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, NCPDP claim rejection resolution, coordination of benefits, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills * Desired: Knowledge of Foundation Funding, Specialty pharmacy experience * Licenses/Certifications * Required: Registration with Board of Pharmacy as required by state law * Desired: Certified Pharmacy Technician (PTCB) * Behavior Competencies * Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills

What you’ll do

The Pharmacy Adjudication Specialist is responsible for adjudicating pharmacy claims, resolving third-party rejections, and ensuring accurate coordination of benefits. They also serve as a liaison to patients and providers regarding financial responsibility and medication delivery status.

Requirements

Candidates must have a High School Diploma or GED and at least 2 years of experience in a pharmacy or healthcare setting. An active Colorado Pharmacy Technician credential is required for this role.

Benefits

• Medical • Dental • Vision • 401k with a match • Paid Time Off • Paid Holidays • Tuition Reimbursement • Life insurance • Short-term disability • Long-term disability • Sign-on bonus

Listed skills

• Time management · Preferred
• Data entry · Preferred
• Communication Skills · Preferred

Other relevant skills

Identified from the job description. Confirm important requirements above.

• Pharmacy claims adjudication
• NCPDP claim rejection resolution
• Coordination of benefits
• Medical billing
• Benefits verification
• Pharmacy terminology
• Insurance claim resolution
• Patient outreach
• Data entry
• Analytical skills
• Time management
• Communication skills
• Medicare knowledge
• Medicaid knowledge
• Commercial insurance knowledge
• CPR+ system
• Copayment Collection And Processing
• Pharmacy Operations
• Claims Resolution
• Productivity Improvement
• Workflow Management
• Ability To Meet Deadlines
• Time Off Management
• Pharmacy Experience
• Advocacy
• Ethical Standards And Conduct
• Analytical Skills
• Adjudication
• Hematology
• Billing
• Medical Billing
• Management
• Certified Pharmacy Technician
• Customer Service
• General Mathematics
• Interpersonal Communications
• Medicaid
• Oncology
• Medical Prescription
• Medicare
• Medical Privacy
• Pharmacy Benefit Management
• State Laws
• Time Management
• Typing
• Writing
• Registration
• Coordinating
• National Drug Code (NDC)
• Detail Oriented

Job areas

• Healthcare
• Customer Service & Support
• Administrative
• Claims Adjudicator
• Claims Adjuster / Specialist (General)
• Valuers and Loss Assessors
• Claims Adjusters, Examiners, and Investigators