Pharmacy Claims Adjudication Specialist

Onco360•Salt Lake, UT

20d

About The Position

Onco360 Pharmacy is seeking a full-time Pharmacy Adjudication Specialist for its specialty pharmacy. The role is based in the Mountain Time Zone and may be performed remotely or in a hybrid arrangement. The shift runs from 10 a.m. to 8 p.m. Mountain Time. Applicants must have active Utah Pharmacy Technician credentials from the State Board of Pharmacy. The specialist adjudicates prescription claims, checks claim responses for accuracy, resolves third-party rejections, and obtains appropriate overrides to support timely medication delivery. The role includes patient and provider outreach about claim issues and delivery delays, patient setup and insurance data entry in CPR+, management of primary, secondary, and tertiary claims, funding-related adjudications, copay-card eligibility checks, and coordination with the Onco360 Advocate team. The specialist also communicates patient financial responsibility, collects applicable payments, documents refund requests, and supports reconciliation of prescription delivery assessments and copay payments before shipment. The position requires a high school diploma or GED and at least two years of experience in a pharmacy or healthcare setting or in pharmacy claims. An associate degree or equivalent two-year or technical-school program, pharmacy technician certification, specialty pharmacy experience, and additional experience are desired. The specialist is expected to follow applicable company policies, professional standards, laws, and patient confidentiality requirements.

Requirements

High school diploma or GED.
At least 2 years of experience in a pharmacy or healthcare setting or pharmacy claims experience.
Active Utah Pharmacy Technician credentials from the State Board of Pharmacy.
Knowledge of pharmacy/NDC medication billing, pharmacy claims resolution, PBM and medical contracts, Medicare, Medicaid, commercial insurance, NCPDP claim rejection resolution, and coordination of benefits.
Pharmacy or healthcare-related knowledge, including pharmacy terminology such as sig codes and Roman numerals, and brand and generic medication names.
Basic math and analytical skills and intermediate typing/keyboarding skills.
Ability to work independently, meet deadlines efficiently, and remain flexible.
Good interpersonal skills, excellent verbal and written communication, attention to detail, and strong time-management skills.

Nice To Haves

Associate degree or equivalent program from a two-year program or technical school.
Certified Pharmacy Technician (PTCB).
Specialty pharmacy experience.
At least 3 years of experience in a pharmacy or healthcare setting or pharmacy claims experience.
Knowledge of Foundation Funding.

Responsibilities

Adjudicate pharmacy claims and review claim responses for accuracy before accepting claims.
Ensure claims are processed correctly according to coordination of benefits, including primary, secondary, and tertiary pharmacy plans.
Resolve third-party claim rejections, contact insurance companies, and obtain overrides when appropriate.
Notify patients or providers and reschedule medication deliveries when unresolved claim issues delay shipment.
Practice first-call resolution by responding to questions and requests from healthcare providers and patients.
Provide timely, accurate information about active claims to pharmacy operations, providers, and patients.
Set up patients accurately in the CPR+ system, including demographic and insurance information.
Apply copay cards only to eligible patients according to established criteria, including insurance type.
Manage funding-related adjudications and liaise with the Onco360 Advocate team.
Help reconcile electronically adjudicated claims and copay payments before medication shipment.
Communicate patient financial responsibility, address copay discrepancies, and collect payments when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy while following procedures, regulations, and confidentiality requirements.
Perform related tasks as needed and conduct work in accordance with the company Code of Business Conduct and Ethics, company policies, the Corporate Compliance Agreement, applicable laws, and professional standards.