Pharmacy Claims Adjudication Specialist

Onco360•Waltham, MA

5d•$26•Hybrid

About The Position

Onco360 Pharmacy is seeking a full-time Pharmacy Claims Adjudication Specialist for its specialty pharmacy in Waltham, Massachusetts. The position has a hybrid work style and must be located within driving distance of the pharmacy. Shift times fall between 8 a.m. and 8 p.m. The specialist adjudicates pharmacy claims and reviews claim responses for accuracy, resolves third-party rejections, obtains appropriate overrides, and notifies patients about medication delivery delays caused by insurance claim rejections. The role also supports patients, providers, and pharmacy operations with claim questions, patient setup, coordination of benefits, funding adjudications, copay processing, and payment collection. Work must be performed in accordance with company policies, applicable laws, professional standards, and patient confidentiality requirements.

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.
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 medication brand and generic 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 orientation and strong time-management skills.

Nice To Haves

Associate degree or equivalent program from a two-year program or technical school.
Certified Pharmacy Technician credential; PTCB certification is specifically desired.
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 by answering healthcare providers’ and patients’ pharmacy-related questions and requests.
Provide thorough, accurate, and timely responses to pharmacy operations, providers, and patients regarding active claims information.
Ensure complete and accurate patient setup in the CPR+ system, including demographic and insurance information.
Adjudicate active-workflow prescription claims for primary, secondary, and tertiary pharmacy plans, and review responses for accuracy before accepting claims.
Contact insurance companies to resolve third-party rejections and obtain appropriate overrides so medications can be shipped on time.
Contact patients or providers to reschedule medication deliveries when claim issues cannot be resolved by the ship date and cause shipment delays.
Apply copay cards only to eligible patients according to set criteria, including insurance-type requirements.
Manage funding-related adjudications and serve as a liaison to the Onco360 Advocate team.
Assist the pharmacy team with electronically adjudicated claims, ensuring prescription delivery assessments are reconciled and copay payments are charged before shipment.
Communicate patients’ financial responsibility before shipment, explain copay discrepancies between quoted amounts and claims, 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 professional practice and patient confidentiality laws.
Contribute to team efforts by completing related tasks and other duties as assigned.
Perform 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.