Pharmacy Claims Adjudication Specialist

Onco360 Oncology Pharmacy; Houston (TX); On-site; USD 23,866 - 33,992; Full time

Benefits offered by this job

401k with a match

Paid Time Off

Tuition Reimbursement

Company paid benefits

Job summary

Onco360 Oncology Pharmacy in Houston, TX is hiring a Pharmacy Claims Adjudication Specialist. This full-time position offers a hybrid work style. Responsibilities include adjudicating claims, ensuring accurate responses for pharmacy operations, and resolving insurance-related issues. The ideal candidate should possess experience in pharmacy claims and a high school diploma, with preferred qualifications including an associate degree and 3+ years in the field. Benefits include a 401k match, PTO, and tuition reimbursement.

Qualifications

• 1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience.
• Independent worker with excellent verbal and written communications skills.
• Detail-oriented with good time-management skills.

Responsibilities

• Adjudicate pharmacy claims and ensure accuracy according to coordination of benefits.
• Provide accurate responses to requests regarding active claims.
• Resolve third-party rejections to allow for timely shipping of medications.

Skills

Pharmacy/NDC medication billing

Pharmacy claims resolution

Knowledge of Medicare/Medicaid

Analytical skills

Intermediate typing/keyboarding skills

Education

High School Diploma or GED

Associate degree or equivalent program

Job description

Overview

Position: Pharmacy Claims Adjudication Specialist

Location: Houston, TX

Job Id: 5092

# of Openings: 1

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Houston, TX. This will be a Full-Time position. This position must be located within driving distance to our pharmacy, with a hybrid work style.

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 $21.00 an hour and up

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

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.
• Document and submit requests for Patient Refunds when appropriate.

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: 1+ 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)
• 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