Pharmacy Claims Adjudication Specialist

Onco360 Oncology Pharmacy · Houston, TX · 1 mo ago

Healthcare$21/hrFull-time

We need to output HTML fragment with sections for headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title as heading. Must not include Job ID etc. Remove boilerplate. We need to parse the posting. Content: - Opening: "We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Houston, TX. 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 $21.00 an hour and up Sign-On Bonus: $5,000 for employees starting before October 31st, 2026. We offer a variety of benefits including: Medical; Dental; Vision401k with a matchPaid Time Off and Paid HolidaysTuition ReimbursementCompany paid benefits – life; and short and long-term disability" Then "Pharmacy Adjudication Specialist Major Responsibilities:" then list of responsibilities (multiple sentences). Then "Pharmacy Adjudication Specialists at Onco360..." continues responsibilities. Then "Pharmacy Adjudication Specialist Qualifications And Responsibilities..." then Education/Learning Experience, Work Experience, Skills/Knowledge, Licenses/Certifications, Behavior Competencies. We need to map to sections: About the role (intro description), Responsibilities, Requirements (maybe combine Education/Learning Experience and Work Experience?), Qualifications (maybe same as Requirements?), Skills, Benefits, Pay, Schedule. We must not create sections with filler. Provide only sections with real content. Let's extract: About the role: description of role, location, hybrid, shift times, company description. That's substantive. Responsibilities: list of duties (adjudicate claims, review claim responses, ensure correct adjudication, resolve third-party rejections, obtain overrides, patient outreach notification, first call resolution, answer questions, provide responses, ensure patient setup in CPR+, adjudicates claims for primary/secondary/tertiary plans, contacts insurance companies, performs outreach calls to reschedule deliveries, ensures copay cards only applied to eligible patients, manages funding related adjudications, works as liaison to Advocate team, assists pharmacy team with management of electronically adjudicated claims, serves as customer service liaison regarding financial responsibility, contacts patients to communicate copay discrepancy, documents and submit requests for patient refunds, maintain safe/clean pharmacy, contributes to team effort, conducts job responsibilities per standards). We'll put as

items. Requirements: maybe combine Education/Learning Experience and Work Experience? The posting has Education/Learning Experience (Required: HS 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...). Could treat as Requirements section. Qualifications: maybe same as Requirements? But we need to avoid duplication. Could treat Qualifications as Licenses/Certifications and Behavior Competencies? However the instruction: Use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we need to decide which content goes where. We have Education/Learning Experience and Work Experience -> could go under Requirements. Skills/Knowledge -> Skills section. Licenses/Certifications -> maybe Qualifications? Or could be part of Requirements. But we have both Requirements and Qualifications headings available. We could put Licenses/Certifications under Qualifications. Behavior Competencies could also be under Qualifications or Skills? Probably Qualifications includes certifications and behavior competencies. Thus: - About the role: intro paragraph. - Responsibilities: list. - Requirements: Education/Learning Experience + Work Experience (maybe combine as bullet list). - Qualifications: Licenses/Certifications + Behavior Competencies. - Skills: Skills/Knowledge. - Benefits: list of benefits. - Pay: Starting salary from $21.00 an hour and up Sign-On Bonus: $5,000 for employees starting before October 31st, 2026. - Schedule: Shift times between 8am and 8pm. Hybrid work style, full-time, must be within driving distance. We must not create sections with filler like "not specified". All have content. Now produce HTML fragment: use
for each section heading. Use
for prose. Use
- for lists. We need to preserve all substantive information; do not invent or summarize away detail. Must not omit details. Let's craft. About the role: combine sentences: "We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Houston, TX. 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." That's all. Responsibilities: need to list each duty as separate
- . Let's extract bullet points from the paragraph. Paragraph after "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" Then continues: "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 delaysEnsures 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.Documents 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." We need to split into sensible items. Let's create list items: - 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 healthcare 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 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 and causes shipment delays. - Ensure copay cards are only applied to claims for eligible patients based on set criteria (e.g., government beneficiaries not eligible). - Manage all funding-related adjudications and work as a liaison to the Onco360 Advocate team. - Assist pharmacy team with management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment. - Serve as customer service liaison to patients regarding financial responsibility prior to shipments, contact patients to communicate any copay discrepancy between quoted amount and claim, 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 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 applicable professional standards. That seems comprehensive. Now Requirements: Education/Learning Experience and Work Experience. 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 or pharmacy claims experience. Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience. We can combine into bullet list, marking required vs desired. Let's produce items: - Required: High School Diploma or GED. - Required: 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. - Desired: Certified Pharmacy Technician. - Desired: Specialty pharmacy experience. - Required: 2+ years experience in a Pharmacy/Healthcare Setting or pharmacy claims experience. - Desired: 3+ years experience in a Pharmacy/Healthcare Setting or pharmacy claims experience. We could also combine required experience lines. Now Qualifications: Licenses/Certifications and Behavior Competencies. Licenses/Certifications: Required: Registration with Board of Pharmacy as required by state law. Desired: Certified Pharmacy Technician (PTCB). 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. We could list as bullet items. Now Skills: 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. We'll list as bullet items. Benefits: list: Medical; Dental; Vision; 401k with a match; Paid Time Off and Paid Holidays; Tuition

Pharmacy Claims Adjudication Specialist

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