Pharmacy Claims Adjudication Specialist

Major Responsibilities

• 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 and obtain overrides if appropriate.
• Be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections.
• 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.
• Safeguards copay cards 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.
• Aids the 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 submits requests for Patient Refunds when appropriate.
• Maintains a safe and clean pharmacy by complying with procedures, rules, and regulations and adhering to professional practice and patient confidentiality laws.

Qualifications and Responsibilities

• Education/Learning Experience: 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.