Pharmacy Claims Adjudication Specialist

Onco360 Oncology Pharmacy; Denver (CO); Hybrid; USD 33,000 - 41,000; Full time

Benefits offered by this job

Medical

Dental

Vision

401k with match

Paid Time Off and Holidays

Tuition Reimbursement

Life Insurance

Disability Insurance

Job summary

Onco360 Pharmacy is seeking a Pharmacy Adjudication Specialist to adjudicate claims, resolve third-party rejections, and ensure accurate patient insurance data in CPR+.

The role supports timely medication delivery in a remote/hybrid setting, with shift hours starting at 10am MT and requires Colorado pharmacy credentials. Beginning hourly pay is $24+, with a $5,000 sign-on bonus for qualifying hires.

Qualifications

• Requires High School diploma or GED with pharmacy/claims experience.
• Prefer an Associate degree or equivalent and PTCB certification.
• Experience with pharmacy claims adjudication and CPT/HCPCS/NDC terminology.

Responsibilities

• Adjudicate pharmacy claims and review responses for accuracy.
• Resolve third-party rejections and obtain overrides when appropriate.
• Contact insurers to resolve claim issues and notify patients of delays.
• Ensure patient setup and insurance data accuracy in CPR+.
• Support timely shipping and copay collection prior to shipment.
• Serve as liaison to patients/providers on financial responsibility.
• Maintain compliance with regulations and company policies.
• Document requests for Patient Refunds when needed.

Skills

Pharmacy/nDC billing

Pharmacy claims resolution

Medicare/Medicaid knowledge

NCPDP rejection resolution

Coordination of benefits

Pharmacy terminology

Basic math & analytics

Typing/keyboard skills

Education

High School Diploma or GED

Associate degree or equivalent

Certified Pharmacy Technician

Job description

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. Shift times start at 10am Mountain Time Zone until 8pm Mountain Time Zone. Full-Time position may work remotely but MUST HAVE ACTIVE COLORADO 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 $24.00 an hour and up. Sign-On Bonus: $5,000 for employees starting before December 31st, 2026. We offer a variety of benefits including:

• Medical; Dental; Vision
• 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. Pharmacy Adjudication Specialists at Onco360 will:

• Practice first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.
• Provide thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information.
• Ensure complete and accurate patient setup in CPR+ system including patient demographic and insurance information.
• Adjudicate pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and review claim responses for accuracy before accepting the claim.
• Contact insurance companies to resolve third-party rejections and ensure pharmacy claim rejections are resolved to allow for timely shipping of medications. Perform outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays.
• Ensure copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible).
• Manage all funding related adjudications and work as a liaison to Onco360 Advocate team.
• Assist 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.
• Serve as customer service liaison to patients regarding financial responsibility prior to shipments, contact patients to communicate any copay discrepancy between quoted amount and claim and collect payment if applicable.
• Document 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.
• Contribute to team effort by accomplishing related tasks as needed and other duties as assigned.
• Conduct 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: Registration with Board of Pharmacy as required by state law
• Desired: Certified Pharmacy Technician (PTCB)

Behavior Competencies

• 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