Pharmacy Claims Adjudication Specialist

Onco360•Pittsburgh, PA

17d•$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, ensures claims are handled correctly according to coordination-of-benefits requirements, resolves third-party rejections, obtains overrides when appropriate, and notifies patients about medication-delivery delays caused by insurance claim rejections. The position may be performed remotely, but requires active Pennsylvania 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 available to employees starting before December 31, 2026. Onco360 describes its pharmacy model as serving community, oncology, and hematology physicians, patients, payers, and manufacturers. The specialist provides first-call resolution and timely responses to pharmacy operations, providers, and patients; maintains accurate patient and insurance setup in the CPR+ system; adjudicates primary, secondary, and tertiary claims; and works with insurers and the Onco360 Advocate team to resolve rejections and manage funding-related adjudications. The role also supports delivery assessments and copay-payment reconciliation, communicates financial responsibility and copay discrepancies to patients, collects payments when applicable, and documents refund requests. The specialist is expected to maintain a safe and clean pharmacy and comply with applicable procedures, rules, regulations, confidentiality requirements, laws, professional standards, and company policies and ethics requirements. Other related duties may be assigned.

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.
Pharmacy Technician License/Registration with the Board of Pharmacy, as required by state law; the posting specifically requires active Pennsylvania 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.
Ability to work independently and efficiently meet deadlines, with flexibility and attention to detail.
Good interpersonal skills, excellent verbal and written communication skills, 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 for health care providers and patients, answering pharmacy-related 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 prescription claims in active workflow 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.
Contact patients or providers to reschedule medication deliveries when unresolved claim rejections cause shipment delays.
Ensure copay cards are applied only to eligible patients according to established criteria, including restrictions for government beneficiaries.
Manage funding-related adjudications and serve as a liaison to the Onco360 Advocate team.
Assist the pharmacy team with electronically adjudicated claims and ensure prescription delivery assessments are reconciled and copay payments are charged before shipment.
Communicate patients’ financial responsibility before shipment, explain copay discrepancies between quoted and claimed amounts, 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, and patient-confidentiality requirements.
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 federal and state laws, and professional standards.