Pharmacy Claims Adjudication Specialist

Onco360•St. Louis, MO

17d•$25

About The Position

Onco360 Pharmacy is seeking a Pharmacy Adjudication Specialist for its specialty oncology pharmacy. This full-time position may be performed remotely, but requires active Missouri Pharmacy Technician credentials from the State Board of Pharmacy. Shift times fall between 8 a.m. and 8 p.m. The starting salary is $25.00 per hour and up. A $5,000 sign-on bonus is offered to employees starting before December 31, 2026. The Pharmacy Adjudication Specialist adjudicates prescription claims, reviews claim responses for accuracy, resolves third-party rejections, obtains appropriate overrides, and informs patients about medication delivery delays caused by insurance claim rejections. The position also supports patients, providers, and pharmacy operations with claims information, patient setup, payment and copay matters, funding adjudications, and timely medication shipment. Onco360 Pharmacy is an oncology pharmacy model serving community, oncology, and hematology physicians, patients, payers, and manufacturers.

Requirements

Active Missouri Pharmacy Technician credentials from the State Board of Pharmacy.
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.
Pharmacy/NDC medication billing and pharmacy claims resolution knowledge.
Knowledge of PBM and medical contracts and understanding of 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 medication brand and generic names.
Basic math and analytical skills and intermediate typing/keyboarding skills.
Independent work ability, interpersonal skills, excellent verbal and written communication, efficiency in meeting deadlines, flexibility, 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.
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 healthcare providers’ and patients’ pharmacy questions and requests.
Provide thorough, accurate, and timely responses to pharmacy operations, providers, and patients regarding active claims 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 appropriate overrides so medications can ship on time.
Contact patients or providers to reschedule medication deliveries when claim issues cannot be resolved by the ship date and delay shipment.
Apply copay cards only to eligible patients according to established criteria, including restrictions for government beneficiaries.
Manage funding-related adjudications and liaise with 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 discrepancies between quoted and adjudicated copays, 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 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, policies and procedures, Corporate Compliance Agreement, applicable laws, and professional standards.