Pharmacy Claims Adjudication Specialist

Onco360•Houston, TX

17d•$20•Hybrid

About The Position

W e are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Houston, TX. This will be a Full-Time position. This position must be located within driving distance to our pharmacy, with a hybrid work style. Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers. Starting salary from $20.00 an hour and up Sign-On Bonus: $5,000 for employees starting before January 1, 2026. We offer a variety of benefits including: Medical; Dental; Vision 401k with a match Paid Time Off and Paid Holidays Tuition Reimbursement Company paid benefits – life; and short and long-term disability Pharmacy Adjudication Specialist Major Responsibilities: The Pharmacy Adjudication Specialist will adjudicate pharmacy claims, review claim responses for accuracy. ensure prescription claims are adjudicated correctly according to the coordination of benefits, resolve any third-party rejections, obtain overrides if appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections Pharmacy Adjudication Specialists at Onco360... Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests. Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information.. Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information. Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim. Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications. Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible) Manages all funding related adjudications and works as a liaison to Onco360 Advocate team. Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment. Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable. Document and submit requests for Patient Refunds when appropriate.

Requirements

High School Diploma or GED
1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience
Pharmacy/NDC medication billing
Pharmacy claims resolution
PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance
NCPDP claim rejection resolution
coordination of benefits
pharmacy or healthcare-related knowledge
knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication
basic math and analytical skills
Intermediate typing/keyboarding skills
Registration with Board of Pharmacy as required by state law
Independent worker
good interpersonal skills
excellent verbal and written communications skills
ability to work independently
work efficiently to meet deadlines and be flexible
detail-oriented
great time-management skills

Nice To Haves

Associate degree or equivalent program from a 2 year program or technical school
Certified Pharmacy Technician
Specialty pharmacy experience
3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience
Knowledge of Foundation Funding
Specialty pharmacy experience
Certified Pharmacy Technician (PTCB)

Responsibilities

adjudicate pharmacy claims
review claim responses for accuracy
ensure prescription claims are adjudicated correctly according to the coordination of benefits
resolve any third-party rejections
obtain overrides if appropriate
responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections
Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests
Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information
Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information
Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim
Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications
Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays
Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)
Manages all funding related adjudications and works as a liaison to Onco360 Advocate team
Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment
Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable
Document and submit requests for Patient Refunds when appropriate