Pharmacy Claims Adjudication Specialist

Onco360 Oncology Pharmacy; Burlington (VT); On-site; USD 52,000 - 70,000; Full time

Benefits offered by this job

401k with match

Paid Time Off

Tuition Reimbursement

Company-paid life and disability benefits

Job summary

Onco360 Oncology Pharmacy is seeking a Pharmacy Claims Adjudication Specialist in Burlington, VT. This full-time role includes adjudicating pharmacy claims, ensuring accuracy, and resolving insurance issues. The position offers remote work options and a starting salary of $25.00 an hour, along with a $5,000 sign-on bonus for early starters.

Applicants should have a High School Diploma or GED and 2+ years of pharmacy or healthcare experience. Benefits include 401k matching, paid time off, and tuition reimbursement.

Qualifications

• Required: Previous experience in Pharmacy, Medical Billing, or Benefits Verification.
• Desired: Certified Pharmacy Technician certification.
• 2+ years experience in Pharmacy/Healthcare Setting.

Responsibilities

• Adjudicate pharmacy claims and review for accuracy.
• Resolve third-party rejections and contact insurance companies.
• Document patient refunds and manage copay payments.

Skills

Pharmacy/NDC medication billing

Pharmacy claims resolution

Knowledge of Medicare and Medicaid

Basic math and analytical skills

Education

High School Diploma or GED

Associate degree in relevant field

Tools

CPR+ system

Job description

Position: Pharmacy Claims Adjudication Specialist

Location: Burlington, VT

Job ID: 5256

# of Openings: 1

We are seeking a Pharmacy Adjudication Specialist for our Specialty Oncology pharmacy.

As our company continues to grow, we strive to hire new team members with a passion for making a difference in our patient's lives.

Full‑time position working out of the State of Vermont. This position may work remotely.

Shift times currently available: 9:00 am–5:30 pm EST or 10:00 am–6:30 pm EST.

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 $25.00 an hour and up.

Sign‑On Bonus: $5,000 for employees starting before July 31, 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 Adjudication Specialist 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.

• 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.
• Documents and submits requests for patient refunds when appropriate.
• Maintains 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 or pharmacy claims experience.
  • Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy 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: Pharmacy Technician License/Registration with Board of Pharmacy as required by state law.
• 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.