Pharmacy Claims Adjudication Specialist
About The Position
W e are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Scottsdale, AZ. This will be a Full-Time position. This is a remote hybrid opportunity, after onsite training period. 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 $23.00 an hour and up Sign-On Bonus: $5,000 for employees starting before February 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...
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
- Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication
- 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
- 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.
Benefits
- Medical
- Dental
- Vision
- 401k with a match
- Paid Time Off and Paid Holidays
- Tuition Reimbursement
- Company paid benefits – life
- short and long-term disability
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
