Pharmacy Claims Adjudication Specialist

Onco360•Buffalo, NY

17d•$23•Hybrid

About The Position

Onco360 Pharmacy is seeking a full-time Pharmacy Adjudication Specialist for its specialty pharmacy in Buffalo, New York. The role uses a hybrid work style, but the employee must live within driving distance of the pharmacy. Shift times fall between 8 a.m. and 8 p.m. The specialist adjudicates pharmacy claims and reviews claim responses for accuracy. They ensure claims are processed correctly according to coordination-of-benefits requirements, resolve third-party rejections, obtain overrides when appropriate, and notify patients about delivery delays caused by insurance claim rejections. The role also involves patient and provider support, accurate patient and insurance setup in CPR+, copay and funding adjudications, payment collection when applicable, and coordination with pharmacy operations and the Onco360 Advocate team. The starting salary is $23.00 per hour and up. A $5,000 sign-on bonus is offered to employees starting before December 31, 2026. Benefits include medical, dental and vision coverage; a 401(k) with match; paid time off and paid holidays; tuition reimbursement; and company-paid life and short- and long-term disability benefits.

Requirements

High school diploma or GED.
At least 2 years of experience in a pharmacy or healthcare setting, or pharmacy claims experience.
Previous experience in pharmacy, medical billing, benefits verification, or pharmacy claims adjudication.
Registration with the Board of Pharmacy as required by state law.
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.
Ability to work independently; good interpersonal skills; excellent verbal and written communication; ability to work efficiently to meet deadlines and be 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, including PTCB certification.
Specialty pharmacy experience.
At least 3 years of experience in a pharmacy or healthcare 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.
Ensure complete and accurate patient setup 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 overrides when appropriate.
Notify patients or providers and reschedule medication deliveries when claim resolution cannot be completed by the ship date and shipment will be delayed.
Ensure copay cards are applied only to eligible patients according to established criteria, including insurance-type restrictions.
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, resolve 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 by following procedures, rules, regulations, and laws concerning professional practice and patient confidentiality.
Contribute to team efforts by completing related tasks and other duties as assigned.
Conduct job 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.