Pharmacy Adjudication Specialist

CareMed Specialty Pharmacy•Waltham, MA

22h•Hybrid

About The Position

We are seeking a Pharmacy Adjudication Specialist at our CareMed Specialty Pharmacy in Waltham, MA. This will be a Full-Time position. This is a remote hybrid opportunity, after onsite training period. Shift time currently available: 9:00 am-5:30 pm CST Starting salary from $26.00 an hour and up Sign-On Bonus: $5,000 for employees starting before July 31, 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

Requirements

High School Diploma or GED.
Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication.
1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience.
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.
Registration with Board of Pharmacy as required by state law.
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.

Nice To Haves

Associate degree or equivalent program from a 2 year program or technical school.
Certified Pharmacy Technician.
Specialty pharmacy experience.
3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience.
Knowledge of Foundation Funding, Specialty pharmacy experience.
Certified Pharmacy Technician (PTCB).

Responsibilities

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.
Responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections.
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.
Documents 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.