Pharmacy Claims Adjudication Specialist

Onco360; Waltham (MA); Hybrid; USD 49,000 - 59,000; Full time

Benefits offered by this job

401k with match

Paid Time Off and Paid Holidays

Tuition Reimbursement

Company paid life and disability

Job summary

Onco360 in Waltham, MA is hiring a Pharmacy Claims Adjudication Specialist for a full-time hybrid role. You will adjudicate pharmacy claims, review responses for accuracy, and resolve third-party rejections to keep medications flowing to patients.

You will interact with providers, payers, and patients, ensuring proper data in CPR+ and proactive outreach when delays occur. Strong pharmacy billing knowledge is essential.

Qualifications

• High School Diploma or GED required; pharmacy or billing background preferred.
• Experience with pharmacy claims adjudication and third-party rejections.
• Knowledge of Medicare/Medicaid and commercial insurance basics.

Responsibilities

• Adjudicate pharmacy claims and review responses for accuracy.
• Resolve third-party rejections and obtain overrides when appropriate.
• Notify patients about delays due to insurance issues and coordinate shipments.
• Maintain patient setup accuracy in CPR+ with demographic and insurance data.
• Serve as liaison to providers, payers, and patients for active claims.

Skills

Pharmacy claims adjudication

PBM knowledge

Medicare/Medicaid knowledge

NCPDP codes

Communication skills

Detail orientation

Education

High School Diploma or GED

Associate degree or equivalent program

Certified Pharmacy Technician

Tools

CPR+ system

Job description

Position:Pharmacy Claims Adjudication Specialist

Location: Waltham, MA

Job Id:5806

# of Openings:1

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

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 $26.00 an hour and up

Sign-On Bonus: $5,000 for employees starting before December 31st, 2026.

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

Pharmacy AdjudicationSpecialist 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.


• Documenst 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 orpharmacy claims experience
  
  
  • Desired: 3+ yearsexperience in Pharmacy/Healthcare Setting orpharmacy 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