Claims Specialist Jobs

About The Position

Requirements

• High school diploma or GED.
• At least 2 years of experience in a pharmacy or healthcare setting or in pharmacy claims.
• Active New Mexico pharmacy technician credentials from the State Board of Pharmacy.
• 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, 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 brand and generic medication names.
• Basic math and analytical skills and intermediate typing/keyboarding skills.
• Ability to work independently, meet deadlines efficiently, and remain flexible.
• Good interpersonal skills and excellent verbal and written communication skills.
• 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 (PTCB).
• Specialty pharmacy experience.
• At least 3 years of experience in a pharmacy or healthcare setting or in pharmacy claims.
• Knowledge of Foundation Funding.

Responsibilities

• Practice first-call resolution by answering questions and requests from health care providers and patients about pharmacy needs.
• Provide thorough, accurate, and timely responses to pharmacy operations, providers, and patients regarding active claims.
• 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 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.
• Ensure copay cards are applied only to eligible patients based on set criteria, including insurance type; government beneficiaries are not eligible.
• Manage funding-related adjudications and act as a liaison to 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, follow up about 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, and laws concerning professional practice and patient confidentiality.
• Contribute to team efforts by completing related tasks and other assigned duties.
• 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.

Benefits

• Medical insurance.
• Dental insurance.
• Vision insurance.
• 401(k) with a company match.
• Paid time off.
• Paid holidays.
• Tuition reimbursement.
• Company-paid life insurance.
• Company-paid short- and long-term disability benefits.
• $5,000 sign-on bonus for employees starting before December 31, 2026.