Pharmacy Claims Adjudication Specialist

Onco360; Pittsburgh (Allegheny County); Hybrid; USD 48,000 - 52,000; Full time

Benefits offered by this job

Medical, Dental, and Vision

401k with a match

Paid Time Off and Paid Holidays

Tuition Reimbursement

Company-paid life and short- and long-term disability benefits

Job summary

JobRx, Inc. is seeking a Pharmacy Adjudication Specialist for their Specialty Oncology pharmacy. This full-time position, based in Pennsylvania, offers remote options and requires experience in pharmacy or medical billing.

The specialist will be responsible for adjudicating pharmacy claims, resolving rejections, and ensuring timely medication delivery. The starting salary is $23.00 per hour with a sign-on bonus of $5,000.

Benefits include medical, dental, vision, 401k match, paid time off, and more.

Qualifications

• Required: 2+ years experience in pharmacy/healthcare setting or pharmacy claims experience.
• Desired: 3+ years experience in pharmacy/healthcare setting or pharmacy claims experience.

Responsibilities

• Adjudicate pharmacy claims and review claim responses for accuracy.
• Ensure prescription claims are adjudicated correctly according to the coordination of benefits.
• Perform outreach calls to patients regarding medication delivery.

Skills

Pharmacy/NDC medication billing

Pharmacy claims resolution

Knowledge of Medicare, Medicaid, and commercial insurance

NCPDP claim rejection resolution

Basic math and analytical skills

Intermediate typing/keyboarding skills

Education

High School Diploma or GED

Pharmacy Technician License/Registration

Job description

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 Pennsylvania. This position may work remotely.

Shift times currently available: 9:00am‑5:30pm EST or 10:00am‑6:30pm 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 $23.00 an hour and up

Sign‑On Bonus: $5,000 for employees starting before July 31, 2026.

Benefits

• Medical, Dental, and Vision
• 401k with a match
• Paid Time Off and Paid Holidays
• Tuition Reimbursement
• Company‑paid life and short‑ and long‑term disability benefits

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 the 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 applied only 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 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.

Qualifications

• 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, 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.
• Behavior Competencies
  • Required: Independent worker, good interpersonal skills, excellent verbal and written communication skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills.