Pharmacy Claims Adjudication Specialist

Onco360•Woodridge, IL

17d•$24•Hybrid

About The Position

Onco360 Pharmacy is seeking a full-time Pharmacy Claims Adjudication Specialist for its specialty pharmacy in Woodridge, Illinois. The role has a hybrid work style, and the employee must live within driving distance of the pharmacy. Shift times are between 8 a.m. and 8 p.m. The starting salary is $24.00 per hour and up. A $5,000 sign-on bonus is available for employees who start before December 31, 2026. The specialist adjudicates pharmacy claims and reviews claim responses for accuracy, ensuring prescription claims are processed correctly according to coordination of benefits. The role resolves third-party rejections, obtains overrides when appropriate, and contacts patients or providers about medication-delivery delays resulting from insurance claim issues. It also supports patients, providers, and pharmacy operations with claim inquiries, financial responsibility, funding-related adjudications, and payment or refund matters.

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 healthcare 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 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.
Registration with the Board of Pharmacy as required by state law.
Ability to work independently and efficiently to meet deadlines, and flexibility, attention to detail, and strong time-management skills.
Good interpersonal skills and excellent verbal and written communication skills.

Nice To Haves

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

Responsibilities

Use first-call resolution to help healthcare providers and patients with pharmacy needs, questions, and requests.
Provide thorough, accurate, and timely responses to pharmacy operations, providers, and patients regarding active claims.
Ensure complete and accurate patient setup in the CPR+ system, including demographic and insurance information.
Adjudicate claims for prescriptions in active workflow across primary, secondary, and tertiary pharmacy plans, and review claim responses for accuracy before accepting claims.
Contact insurance companies to resolve third-party rejections so medications can be shipped promptly.
Contact patients or providers to reschedule medication deliveries when unresolved claim issues cause shipment delays.
Ensure copay cards are applied only to eligible patients based on established criteria, including insurance type.
Manage funding-related adjudications and serve as a liaison to the Onco360 Advocate team.
Assist the pharmacy team with electronically adjudicated claims, ensuring prescription delivery assessments are reconciled and copay payments are charged before shipment.
Communicate patients’ financial responsibility before shipment, explain copay discrepancies between quoted amounts and claims, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy in accordance with procedures, rules, regulations, professional practice, and patient confidentiality laws.
Contribute to team efforts by completing related tasks and other assigned duties.
Perform responsibilities in accordance with 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.