Pharmacy Claims Adjudication Specialist

About the role

This is a full-time, remote/hybrid opportunity for a Pharmacy Adjudication Specialist based in the Mountain Time Zone. Shift times start at 10:00 AM and end at 8:00 PM Mountain Time. Candidates must hold active Colorado Pharmacy Technician credentials from the State Board of Pharmacy.

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

Pay

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

Benefits

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

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 regarding delays 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 to requests from pharmacy operations, providers, and patients regarding active claims.
• Ensure complete and accurate patient setup in the CPR+ system, including patient demographic and insurance information.
• Adjudicate pharmacy claims 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 timely shipping of medications.
• Perform outreach calls to patients or providers to reschedule medication deliveries if claim resolution causes shipment delays.
• 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 ensure delivery assessments are reconciled and copay payments are charged prior to shipment.
• Serve as a customer service liaison to patients regarding financial responsibility prior to shipments, communicate copay discrepancies, and collect payments 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, policies, procedures, and applicable laws.

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).
• Previous experience in pharmacy, medical billing, benefits verification, or pharmacy claims adjudication.
• Specialty pharmacy experience (desired).
• Certified Pharmacy Technician (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).
• 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.

Qualifications

• Registration with the Board of Pharmacy as required by state law (required).
• Certified Pharmacy Technician (PTCB) (desired).