Pharmacy Claims Adjudication Specialist

Onco360•Salt Lake City, UT

17d•$23

About The Position

Onco360 Pharmacy is seeking a full-time Pharmacy Adjudication Specialist for its specialty pharmacy. The role is a remote/hybrid opportunity and requires active Utah Pharmacy Technician credentials from the State Board of Pharmacy. The work shift runs from 10 a.m. to 8 p.m. Mountain Time. Starting pay is $23.00 per hour and up, with a $5,000 sign-on bonus for employees who start before December 31, 2026. The Pharmacy Adjudication Specialist adjudicates prescription claims, checks claim responses for accuracy, coordinates benefits, resolves third-party rejections, obtains appropriate overrides, and notifies patients about delivery delays caused by insurance claim issues. The role also supports patient and provider inquiries, patient and insurance setup, copay and funding adjudications, payment collection and refund requests, and timely medication shipment. The specialist must follow pharmacy procedures, professional standards, company policies, applicable laws, 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.
Active Utah Pharmacy Technician credentials from the State Board of Pharmacy are required for the remote/hybrid opportunity.
Registration with a Board of Pharmacy as required by state law.
Knowledge of pharmacy/NDC medication billing, pharmacy claims resolution, PBM and medical contracts, 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 brand and generic medication names.
Basic math and analytical skills and intermediate typing/keyboarding skills.
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, with strong attention to detail and time-management skills.

Nice To Haves

Associate degree or equivalent program from a two-year program or technical school.
Certified Pharmacy Technician (PTCB).
Three or more years of experience in a pharmacy or healthcare setting, or pharmacy claims experience.
Specialty pharmacy experience.
Knowledge of Foundation Funding.

Responsibilities

Practice first-call resolution by answering health care 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 claim responses for accuracy before accepting claims.
Contact insurance companies to resolve third-party rejections and obtain appropriate overrides to support timely medication shipping.
Contact patients or providers to reschedule medication deliveries when unresolved claim issues cause shipment delays.
Ensure copay cards are applied only to eligible patients according to established criteria, including restrictions for government beneficiaries.
Manage funding-related adjudications and act 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, address discrepancies between quoted copays and claims, and collect payment when applicable.
Document and submit patient refund requests when appropriate.
Maintain a safe and clean pharmacy by following procedures, rules, regulations, professional practice standards, and patient confidentiality laws.
Contribute to team efforts by completing related tasks and other duties as assigned.
Perform 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 professional standards.