Pharmacy Claims Adjudication Specialist

Onco360•Louisville, KY

5d•$21•Hybrid

About The Position

Onco360 Pharmacy is a specialty oncology pharmacy serving community, oncology and hematology physicians, patients, payers, and manufacturers. The Pharmacy Claims Adjudication Specialist works at the Louisville, Kentucky pharmacy and must live within driving distance. The role has a hybrid work style and full-time hours, with shift times currently scheduled between 8 a.m. and 8 p.m. Starting pay is $21.00 per hour or more. A $5,000 sign-on bonus is offered to employees who start before December 31, 2026. The specialist adjudicates pharmacy claims and reviews responses for accuracy, resolves third-party rejections, obtains overrides when appropriate, and contacts patients or providers about delivery delays caused by insurance claim issues. The role also supports patient setup, coordination of benefits, funding and copay adjudication, payment collection, and reconciliation of prescription delivery assessments. The specialist follows company policies, professional standards, applicable laws, and patient confidentiality requirements.

Requirements

High school diploma or GED.
At least 2 years of experience in a pharmacy or healthcare setting, or pharmacy claims experience.
Experience in pharmacy, medical billing, benefits verification, or pharmacy claims adjudication.
Knowledge of pharmacy/NDC medication billing and pharmacy claims resolution.
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 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, with good interpersonal skills and excellent verbal and written communication skills.
Ability to work efficiently to meet deadlines and remain flexible; detail-oriented with strong time-management skills.
Must be located within driving distance of the Louisville, Kentucky pharmacy.

Nice To Haves

Associate degree or equivalent program from a two-year program or technical school.
Certified Pharmacy Technician certification, including PTCB.
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 when assisting 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.
Set up patients accurately and completely 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 be shipped on time.
Contact patients or providers to 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 based on established criteria, including insurance type.
Manage funding-related adjudications and act as a liaison to the Onco360 Advocate team.
Help manage electronically adjudicated claims, reconcile prescription delivery assessments, and ensure copay payments are charged 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 standards, and patient confidentiality laws.
Complete 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 applicable professional standards.