Pharmacy Claims Adjudication Specialist

Onco360•New Hyde Park, NY

17d•$26•Hybrid

About The Position

Onco360 Pharmacy is seeking a full-time Pharmacy Adjudication Specialist for its specialty pharmacy in New Hyde Park, New York. The position requires being within driving distance of the pharmacy and uses a hybrid work style. Shift times fall between 8 a.m. and 8 p.m. The specialist adjudicates pharmacy claims and checks claim responses for accuracy, including coordinating benefits, resolving third-party rejections, and obtaining overrides when appropriate. The role also involves contacting patients or providers about delivery delays caused by insurance claim rejections, supporting accurate patient and insurance setup, managing copay and funding adjudications, and helping ensure payments and delivery assessments are completed before shipments. The role requires a high school diploma or GED and at least two years of experience in a pharmacy or healthcare setting or pharmacy claims. Registration with the Board of Pharmacy is required when state law requires it. An associate degree, Certified Pharmacy Technician credential, and specialty pharmacy experience are desired. The company describes its values as Teamwork, Respect, Integrity, and Passion.

Requirements

High school diploma or GED.
At least 2 years of experience in a pharmacy or healthcare setting or pharmacy claims experience.
Registration with the Board of Pharmacy as required by state law.
Knowledge of pharmacy/NDC medication billing, pharmacy claims resolution, PBM and medical contracts, Medicare, Medicaid, commercial insurance, 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, and to be flexible and detail-oriented with 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 credential; PTCB certification is desired.
Specialty pharmacy experience.
Knowledge of Foundation Funding.
Three or more years of experience in a pharmacy or healthcare setting or pharmacy claims experience.

Responsibilities

Practice first-call resolution by answering 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 overrides when appropriate.
Contact patients or providers to reschedule medication deliveries when unresolved claim rejections delay shipment.
Ensure copay cards are applied only to eligible patients according to criteria, including insurance type.
Manage funding-related adjudications and liaise with 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, address copay discrepancies, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy and comply with procedures, rules, regulations, professional practice requirements, 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 laws, and professional standards.