Pharmacy Claims Adjudication Specialist

Onco360•Burlington, VT

5d•$25•Remote

About The Position

Onco360 Pharmacy is seeking a Pharmacy Adjudication Specialist for its Specialty Oncology pharmacy. This full-time position may be performed remotely, but requires active Vermont Pharmacy Technician credentials from the State Board of Pharmacy. Shift times fall between 8 a.m. and 8 p.m. The starting salary is $25.00 per hour and up. A $5,000 sign-on bonus is available to employees who start before December 31, 2026. The Pharmacy Adjudication Specialist adjudicates pharmacy claims and reviews claim responses for accuracy. The role ensures prescriptions are adjudicated according to coordination-of-benefits requirements, resolves third-party rejections, obtains appropriate overrides, and notifies patients about delivery delays caused by insurance claim rejections. The specialist also supports patient and provider inquiries, maintains accurate patient and insurance records, coordinates claim and copay processes, and helps ensure prescriptions can be shipped on time. Onco360 Pharmacy describes itself as a unique oncology pharmacy model serving community, oncology, and hematology physicians, patients, payers, and manufacturers.

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.
Active Pharmacy Technician license or registration with the Board of Pharmacy as required by state law; the position specifically requires active Vermont 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, 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.
Ability to work independently and efficiently to meet deadlines, flexibility, attention to detail, strong time-management skills, good interpersonal skills, and excellent verbal and written communication 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

Practice first-call resolution by responding to healthcare providers’ and patients’ pharmacy 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 unresolved claims cause shipment delays.
Ensure copay cards are applied only to eligible patients under established criteria, including the exclusion of government beneficiaries.
Manage funding-related adjudications and liaise with the Onco360 Advocate team.
Assist the pharmacy team in managing electronically adjudicated claims, reconciling prescription delivery assessments, and ensuring copay payments are charged before shipment.
Communicate patients’ financial responsibility before shipment, explain copay discrepancies between quoted and adjudicated amounts, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy by following procedures, rules, regulations, and requirements related to professional practice and patient confidentiality.
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, company policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and professional standards.