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.
• PRACTICE first call resolution to help health care providers and patients with their 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 reviews 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 their 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 such as insurance type (government beneficiaries not eligible).
• Manage all funding related adjudications and work as a liaison to Onco360 Advocate team.
• Assist 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.
• 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.
• Contribute to team effort by accomplishing related tasks as needed and other duties as assigned.
• Conduct 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.

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.