Pharmacy Claims Adjudication Specialist

Onco360•Saint Louis, MO

7d•Remote

About The Position

Onco360 Pharmacy is seeking a Pharmacy Adjudication Specialist for its Specialty Oncology pharmacy. The role adjudicates pharmacy claims, verifies claim responses, resolves third-party rejections, and supports timely medication shipment. It also involves patient and provider communications, accurate patient and insurance setup, payment and copay handling, funding-related adjudications, and maintaining compliance with pharmacy procedures, laws, and professional standards. The position may be performed remotely and requires active Missouri Pharmacy Technician credentials from the State Board of Pharmacy. Shift times fall between 8 a.m. and 8 p.m. Starting pay is $25.00 per hour and up. A $5,000 sign-on bonus is offered to employees starting before December 31, 2026.

Requirements

High school diploma or GED.
Previous experience in pharmacy, medical billing, or benefits verification.
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; the posting specifically requires active Missouri 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, 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, meet deadlines efficiently, and remain flexible.
Good interpersonal skills and excellent verbal and written communication skills.
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

Adjudicate pharmacy claims and review claim responses for accuracy, including primary, secondary, and tertiary plans.
Ensure claims are adjudicated correctly according to coordination of benefits and resolve third-party rejections, obtaining overrides when appropriate.
Respond to health care providers’ and patients’ questions and requests, aiming for first-call resolution and providing timely, accurate information about active claims.
Set up patients completely and accurately in the CPR+ system, including demographic and insurance information.
Contact insurance companies to resolve claim rejections so medications can be shipped on time.
Contact patients or providers to reschedule deliveries when unresolved claim issues cause shipment delays.
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.
Help reconcile electronically adjudicated claims and prescription delivery assessments, and ensure copay payments are charged before shipment.
Communicate patients’ financial responsibility before shipment, address copay discrepancies, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy in compliance with procedures, rules, regulations, and confidentiality requirements.
Complete related tasks and other duties as assigned.
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.