Pharmacy Claims Adjudication Specialist

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. This is a Full‑Time position located within driving distance of the Waltham, MA specialty pharmacy, with a hybrid work style.

Responsibilities

• Adjudicate pharmacy claims and review claim responses for accuracy.
• Ensure prescription claims are adjudicated correctly according to coordination of benefits.
• Resolve any third‑party rejections and obtain overrides if appropriate.
• Perform patient outreach notification regarding any delay in medication delivery due to insurance claim rejections.
• Practice first call resolution to help health care providers and patients with 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 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