Pharmacy Claims Adjudication Specialist

Onco360•Houston, TX

5d•$21•Hybrid

About The Position

Onco360 Pharmacy is hiring a full-time Pharmacy Adjudication Specialist for its specialty pharmacy in Houston, Texas. The position has a hybrid work style and must be located within driving distance of the pharmacy. Shift times fall between 8 a.m. and 8 p.m. The specialist adjudicates pharmacy claims and checks claim responses for accuracy. The role includes resolving third-party rejections, obtaining appropriate overrides, and notifying patients about delivery delays caused by insurance claim rejections. The specialist also supports pharmacy operations, providers, and patients with active-claim requests; maintains accurate patient and insurance information in the CPR+ system; and helps ensure claims, delivery assessments, and copay payments are reconciled before shipment. The role also involves eligibility checks for copay cards, funding-related adjudications, patient communication about financial responsibility and copay discrepancies, payment collection when applicable, and submitting patient refund requests. The specialist must comply with pharmacy procedures, professional standards, confidentiality requirements, company policies, and applicable laws.

Requirements

High school diploma or GED.
Previous experience in pharmacy, medical billing, benefits verification, or pharmacy claims adjudication.
At least 2 years of experience in a pharmacy or health care setting, or pharmacy claims experience.
Knowledge of pharmacy/NDC medication billing, pharmacy claims resolution, PBM and medical contracts, Medicare, Medicaid, and commercial insurance.
Knowledge of NCPDP claim rejection resolution and coordination of benefits.
Pharmacy or health care-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.
Registration with the Board of Pharmacy as required by state law.
Ability to work independently; good interpersonal skills; excellent verbal and written communication; ability to work efficiently to meet deadlines and remain flexible; 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 credential; PTCB certification is specifically desired.
Specialty pharmacy experience.
At least 3 years of experience in a pharmacy or health care setting, or pharmacy claims experience.
Knowledge of Foundation Funding.

Responsibilities

Practice first-call resolution by answering health care providers’ and patients’ pharmacy questions and requests.
Provide thorough, accurate, and timely responses to pharmacy operations, providers, and patients regarding active claim information.
Set up patients completely and accurately in the CPR+ system, including demographic and insurance information.
Adjudicate active-workflow prescription claims for primary, secondary, and tertiary pharmacy plans, and review claim responses for accuracy before accepting claims.
Contact insurance companies to resolve third-party rejections and obtain appropriate overrides so medications can ship on time.
Contact patients or providers to reschedule medication deliveries when unresolved claim issues cause shipment delays.
Apply copay cards only to eligible patients according to established criteria, including insurance-type restrictions.
Manage funding-related adjudications and liaise with the Onco360 Advocate team.
Assist the pharmacy team with electronically adjudicated claims and reconcile prescription delivery assessments and copay payments before shipment.
Communicate patients’ financial responsibility before shipment, address discrepancies between quoted copays and claim amounts, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy and comply with procedures, regulations, professional practice requirements, and patient confidentiality laws.
Perform related tasks and other duties as assigned.
Conduct job responsibilities in accordance with the company’s Code of Business Conduct and Ethics, policies and procedures, Corporate Compliance Agreement, applicable laws, and professional standards.