Pharmacy Claims Adjudication Specialist

Onco360•Columbus, OH

4d•$23•Remote

About The Position

Onco360 Pharmacy is seeking a Pharmacy Adjudication Specialist for its Specialty Oncology pharmacy. The role adjudicates pharmacy claims and reviews claim responses for accuracy, ensuring prescription claims are handled correctly according to coordination of benefits. The specialist resolves third-party rejections, obtains overrides when appropriate, and notifies patients about medication-delivery delays caused by insurance claim rejections. The position is full-time and may be remote, but requires active Ohio Pharmacy Technician credentials from the State Board of Pharmacy. Shift times fall between 8 a.m. and 8 p.m. Starting pay is $23.00 per hour and up. A $5,000 sign-on bonus is offered to employees starting before December 31, 2026. Onco360 is an oncology pharmacy model serving community, oncology, and hematology physicians, patients, payers, and manufacturers. The specialist provides first-call resolution and timely, accurate responses to pharmacy operations, providers, and patients. Responsibilities include maintaining complete patient and insurance information in CPR+, adjudicating claims for primary, secondary, and tertiary plans, resolving rejections with insurers, coordinating delivery changes when claims cannot be resolved before shipment, and ensuring copay cards are applied only to eligible patients. The role also manages funding-related adjudications, supports reconciliation of prescription delivery assessments and copay payments, communicates and collects patient financial responsibility when applicable, and submits refund requests. The specialist maintains a safe and clean pharmacy, protects patient confidentiality, follows applicable laws and professional standards, and performs other assigned duties in accordance with company policies and compliance requirements.

Requirements

High school diploma or GED.
At least 2 years of experience in a pharmacy or healthcare setting, or pharmacy claims experience.
Active Pharmacy Technician license or registration with the Board of Pharmacy as required by state law; this position specifically requires active Ohio Pharmacy Technician credentials from the State Board of Pharmacy.
Knowledge of pharmacy/NDC medication billing and pharmacy claims resolution.
Knowledge of PBM and medical contracts.
Knowledge 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 brand and generic medication names.
Basic math and analytical skills and intermediate typing/keyboarding skills.
Independent worker with good interpersonal skills and excellent verbal and written communication skills.
Ability to work independently and efficiently to meet deadlines, while remaining flexible and detail-oriented and demonstrating strong time-management skills.

Nice To Haves

Associate degree or equivalent program 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.

Responsibilities

Practice first-call resolution by answering healthcare-provider and patient questions and requests about pharmacy needs.
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 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 so medications can ship on time.
Notify patients or providers and reschedule medication deliveries when claim-resolution delays prevent shipment by the planned ship date.
Ensure copay cards are applied only to eligible patients according to established criteria, including excluding government beneficiaries where applicable.
Manage funding-related adjudications and liaise with the Onco360 Advocate team.
Assist the pharmacy team in managing electronically adjudicated claims and reconciling prescription delivery assessments and copay payments before shipment.
Communicate patients’ financial responsibility before shipment, explain copay discrepancies, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy and comply with procedures, rules, regulations, professional practice requirements, and patient-confidentiality laws.
Perform related tasks and other duties as assigned.
Conduct work in accordance with the Company’s Code of Business Conduct and Ethics, company policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and professional standards.