Pharmacy Claims Adjudication Specialist

Onco360; St. Louis (MO); On-site; USD 52,000 - 65,000; Full time

Benefits offered by this job

Medical, Dental, Vision

401k with a match

Paid Time Off and Paid Holidays

Tuition Reimbursement

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

Job summary

JobRx, Inc. is seeking a Pharmacy Adjudication Specialist to work full-time in St. Louis, Missouri, with options for remote work. Responsibilities include adjudicating pharmacy claims and resolving third-party rejections.

The ideal candidate should have a High School Diploma or GED, with at least 2 years of experience in a pharmacy or healthcare setting. Benefits include a competitive starting salary, health insurance, and a $5,000 sign-on bonus for early starters.

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 ensure accuracy according to coordination of benefits.
• Resolve third-party rejections and notify patients regarding medication delivery delays.

Skills

Pharmacy/NDC medication billing

pharmacy claims resolution

knowledge of Medicare, Medicaid, and commercial insurance

basic math and analytical skills

Education

High School Diploma or GED

Associate degree or equivalent from a 2-year program

Job description

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

Full‑time position based in the State of Missouri; remote work available.

Shift times currently available: 8:00 am – 4:30 pm CST or 9:00 am – 5:30 pm CST.

Starting salary from $25.00 an hour and up. Sign‑on bonus: $5,000 for employees starting before July 31 2026.

Benefits

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

Key Responsibilities

• Adjudicate pharmacy claims, review claim responses for accuracy and ensure prescription claims are adjudicated correctly according to coordination of benefits.
• Resolve any third‑party rejections, obtain overrides when appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections.
• Practice first‑call resolution to help healthcare 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 the 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 the 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 ensuring 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.

Qualifications

• Education
  • Required: High School Diploma or GED. Previous experience in pharmacy, medical billing, or benefits verification, pharmacy claims adjudication.
  • Desired: Associate degree or equivalent 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 of Medicare, Medicaid, and commercial insurance; NCPDP claim rejection resolution; coordination of benefits; pharmacy or healthcare‑related knowledge; understanding 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.