Pharmacy Claims Adjudication Specialist

Onco360 Oncology Pharmacy; St. Louis (MO); Hybride; USD 52 000 - 70 000; Plein temps

Avantages offerts par ce poste

Medical, Dental, Vision

401k with match

Paid Time Off and Paid Holidays

Tuition Reimbursement

Company paid life and disability

Résumé du poste

Onco360 Oncology Pharmacy is seeking a Pharmacy Adjudication Specialist to adjudicate claims and manage insurance interactions. You will help ensure timely delivery and accurate patient billing, while supporting the pharmacy team in claims processing.

The role requires MO pharmacy technician credentials, and may be remote or hybrid with shifts 8am–8pm. Starting pay is $25/hour plus a $5,000 sign-on bonus for new hires before 12/31/2026.

Qualifications

• Education: High School Diploma or GED; experience in Pharmacy, Medical Billing, or Claims Adjudication.
• Desired: Associate degree or equivalent; Certified Pharmacy Technician; Specialty pharmacy experience.
• Work Experience: 2+ years in Pharmacy/Healthcare or claims experience; 3+ years preferred.
• Knowledge of Medicare/Medicaid/Commercial insurance and PBM contracts.

Responsabilités

• Adjudicate pharmacy claims and review claim responses for accuracy.
• Resolve third-party rejections and obtain overrides where appropriate.
• Notify patients about delays in medication delivery due to insurance issues.
• Ensure accurate patient setup in CPR+ including demographics and insurance.
• Contact insurers to resolve rejections and reschedule deliveries if needed.
• Apply copay cards only to eligible patients.
• Coordinate with Onco360 Advocate team on funding adjudications.
• Assist with management of electronically adjudicated claims and copay payments.
• Communicate copay discrepancies to patients and collect payments.
• Document and submit requests for Patient Refunds when appropriate.
• Maintain safety and confidentiality; comply with laws and ethics.

Connaissances

Pharmacy/NDC medication billing

Pharmacy claims resolution

PBM and Medical contracts

Medicare/Medicaid/Commercial insurance

NCPDP claim rejection resolution

Coordination of benefits

Pharmacy terminology (sig codes, Roman

Brand/generic names of medication

Basic math and analytical skills

Typing / keyboarding

Formation

High School Diploma or GED

Associate degree or equivalent program

Certified Pharmacy Technician

Outils

CPR+ system

Description du poste

W e 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 may work remotely but MUST HAVE ACTIVE MISSOURI PHARMACY TECHNICIAN credentials from the State Board of Pharmacy.

Shift times between 8am and 8pm.

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 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...

• 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 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 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
• 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