Pharmacy Claims Adjudication Specialist

Onco360 Oncology Pharmacy; Waltham (MA); On-site; USD 26,000 - 30,000; Full time

Benefits offered by this job

401(k) with match

Paid Time Off and Paid Holidays

Tuition Reimbursement

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

Job summary

Onco360 Oncology Pharmacy in Waltham, MA, is seeking a Pharmacy Claims Adjudication Specialist to adjudicate pharmacy claims, resolve third-party rejections, and conduct patient outreach. The ideal candidate will have a high school diploma or GED, at least one year of experience in a pharmacy or healthcare setting, and strong knowledge of pharmacy medication billing and insurance processes. This role offers a hybrid work style along with comprehensive benefits including a 401(k) match and tuition reimbursement.

Qualifications

• High School Diploma or GED required, plus experience in pharmacy or claims adjudication.
• 1+ years of experience in pharmacy or healthcare setting required.
• Knowledge of pharmacy terminology and coordination of benefits is essential.

Responsibilities

• Adjudicate pharmacy claims and resolve third-party rejections.
• Conduct patient outreach regarding delays in medication deliveries.
• Respond to providers' and patients' inquiries as first-point resolution.

Skills

Pharmacy/NDC medication billing

Pharmacy claims resolution

Knowledge of Medicare and Medicaid

Basic math and analytical skills

Excellent communication skills

Education

High School Diploma or GED

Associate degree or equivalent

Job description

Position

Pharmacy Claims Adjudication Specialist

Location

Waltham, MA – must be located within driving distance to our pharmacy with a hybrid work style.

Job Id

5093

Openings

1

Salary

Starting salary from $26.00 an hour and up.

Benefits

• 401(k) with match
• Paid Time Off and Paid Holidays
• Tuition Reimbursement
• Company‑paid benefits – life; and short and long‑term disability

Responsibilities

The Pharmacy Adjudication Specialist will:

• 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 ensure timely shipping of medications.
• Conduct patient outreach notifications regarding delays in medication delivery due to insurance claim rejections.
• Respond to health‑care providers and patients’ pharmacy needs as first‑point resolution, answering questions and requests.
• Provide thorough, accurate, and timely responses to requests from pharmacy operations, providers, or patients regarding active claims information.
• Ensure complete and accurate patient setup in CPR+ system, including demographic and insurance information.
• 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 medication deliveries if claim resolution cannot be completed by ship date.
• 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 serve as liaison to the Onco360 Advocate team.
• Assist pharmacy team with management of electronically adjudicated claims to reconcile all prescription delivery assessments and charge copay payments prior to shipment.
• Serve as customer‑service liaison to patients regarding financial responsibility prior to shipments, contact patients to communicate any copay discrepancy and collect payment if applicable.
• Document and submit requests for patient refunds when appropriate.

Qualifications

• Education/Learning Experience
  • Required: High School Diploma or GED. Previous experience in pharmacy, medical billing, benefits verification, or pharmacy claims adjudication.
  • Desired: Associate degree or equivalent from a two‑year program or technical school; Certified Pharmacy Technician; specialty pharmacy experience.
• Work Experience
  • Required: 1+ year experience in a pharmacy or healthcare setting or pharmacy claims experience.
  • Desired: 3+ years experience in a pharmacy or 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: 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 and efficiently to meet deadlines and be flexible, detail‑oriented, great time‑management skills.