Pharmacy Claims Adjudication Specialist

Onco360; Albuquerque (NM); Hybrid; USD 25.000 - 36.000; Vollzeit

Benefits dieser Stelle

401k with match

Paid Time Off & Holidays

Tuition Reimbursement

Life and disability insurance

Zusammenfassung

Onco360 is seeking a Pharmacy Claims Adjudication Specialist in Albuquerque, NM. This full-time, remote/hybrid role requires NM Pharmacy Technician credentials and offers a starting hourly rate with a sign-on bonus for early applicants.

The specialist adjudicates pharmacy claims, reviews responses for accuracy, and communicates with payers and patients to ensure timely delivery of medications. Onco360 provides benefits including 401k, PTO, tuition reimbursement, and disability coverage.

Qualifikationen

• High School Diploma or GED; experience in Pharmacy, Medical Billing, or Benefits Verification.

Aufgaben

• Adjudicate pharmacy claims and review claim responses for accuracy.
• Resolve third-party rejections and obtain overrides when appropriate.
• Conduct patient outreach regarding delays due to insurance claims.

Kenntnisse

Pharmacy claims billing

PBM contracts

Medicare knowledge

Medicaid knowledge

Coordination of benefits

Customer service

Basic math & analytics

Typing speed

Pharmacy terminology

Communication skills

Ausbildung

High School Diploma or GED

Associate degree or equivalent

Certified Pharmacy Technician

Tools

CPR+ system

Jobbeschreibung

Position:Pharmacy Claims Adjudication Specialist

Location: Albuquerque, NM

Job Id:5793

# of Openings:1

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy working in Mountain Time Zone.This will be a Full-Time position. This is a remote/hybrid opportunity,

Full-Time position may work remotely but MUST HAVE ACTIVE NEW MEXICO PHARMACY TECHNICIAN credentials from the State Board of Pharmacy.

Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.

Starting salary from $22.00 an hour and up

Sign-On Bonus: $5,000 for employees starting before December 31st, 2026.

We offer a variety of benefits including:

• 401k with a match
• Paid Time Off and Paid Holidays
• Tuition Reimbursement
• Company paid benefits – life; and short and long-term disability

Pharmacy AdjudicationSpecialist Major Responsibilities:

The Pharmacy Adjudication Specialist will adjudicate pharmacy claims, review claim responses for accuracy. ensure prescription claims are adjudicated correctly according to the coordination of benefits, resolve any third-party rejections, obtain overrides if appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections

Pharmacy Adjudication Specialists at Onco360...

• Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.
• Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information..
• Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.
• Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim.
• Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications. Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays
• Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)
• Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.
• Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment.
• Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable.
• Documenst and submit requests for Patient Refunds when appropriate.
• Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws.
• Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.
• Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.

Pharmacy Adjudication Specialist Qualifications and Responsibilities...

• Education/Learning Experience
  • Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication
  • Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience
• Work Experience
  • Required: 2+ years experience in Pharmacy/Healthcare Setting orpharmacy claims experience
  • Desired: 3+ yearsexperience in Pharmacy/Healthcare Setting orpharmacy claims experience
• Skills/Knowledge
  • Required:Pharmacy/NDC medication billing, Pharmacy claims resolution, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, NCPDP claim rejection resolution, coordination of benefits, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills
  • Desired: Knowledge of Foundation Funding, Specialty pharmacy experience
• Licenses/Certifications
  • Required:Registration with Board of Pharmacy as required by state law
  • Desired:Certified Pharmacy Technician (PTCB)
• Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills