Pharmacy Claims Adjudication Specialist

This is a full-time, hybrid position located in Woodridge, IL; candidates must live within driving distance of the pharmacy. Shifts fall between 8:00 AM and 8:00 PM.

About the role

Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.

Responsibilities

• Adjudicate pharmacy claims and review claim responses for accuracy.
• Ensure prescription claims are adjudicated correctly according to coordination of benefits.
• Resolve third-party rejections and obtain overrides when appropriate.
• Perform patient outreach to notify of any delay in medication delivery due to insurance claim rejections.
• Practice first-call resolution to assist healthcare providers and patients with pharmacy needs, answering questions and requests.
• Provide thorough, accurate, and timely responses regarding active claims information to pharmacy operations, providers, and patients.
• 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; review claim responses for accuracy before accepting the claim.
• Contact insurance companies to resolve third-party rejections and ensure timely shipping of medications.
• Perform outreach calls to patients or providers to reschedule medication deliveries if claim resolution cannot be completed by the ship date.
• Ensure copay cards are applied only to claims for eligible patients based on criteria such as insurance type (Government beneficiaries not eligible).
• Manage all funding-related adjudications and serve as a liaison to the Onco360 Advocate team.
• Assist the pharmacy team with management of electronically adjudicated claims to reconcile prescription delivery assessments and ensure copay payments are charged prior to shipment.
• Serve as a 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.
• Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations, and ensure 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 Company’s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and professional standards.

Requirements

• High School Diploma or GED (required).
• Associate degree or equivalent from a 2-year program or technical school (desired).
• 2+ years of experience in a pharmacy/healthcare setting or pharmacy claims experience (required).
• 3+ years of experience in a pharmacy/healthcare setting or pharmacy claims experience (desired).
• Registration with the Board of Pharmacy as required by state law (required).
• Certified Pharmacy Technician (PTCB) (desired).

Skills

• Pharmacy/NDC medication billing.
• Pharmacy claims resolution and PBM/Medical contracts.
• Knowledge of Medicare, Medicaid, and commercial insurance.
• NCPDP claim rejection resolution and coordination of benefits.
• Pharmacy or healthcare-related knowledge, including pharmacy terminology (sig codes, Roman numerals, brand/generic names of medication).
• Basic math and analytical skills.
• Intermediate typing/keyboarding skills.
• Knowledge of Foundation Funding (desired).
• Specialty pharmacy experience (desired).
• Independent worker with excellent interpersonal, verbal, and written communication skills.
• Ability to work efficiently to meet deadlines, be flexible, detail-oriented, and possess great time-management skills.

Benefits

• Medical, dental, and vision coverage.
• 401k with company match.
• Paid time off and paid holidays.
• Tuition reimbursement.
• Company-paid life insurance and short/long-term disability.

Pay

Starting salary from $24.00 per hour. Sign-on bonus of $5,000 for employees starting before September 30, 2026.