Pharmacy Claims Adjudication Specialist

This is a full-time, hybrid position located within driving distance of our Houston, TX pharmacy. Shift times are between 8 am and 8 pm.

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.

Starting salary from $21.00 an hour with a $5,000 sign-on bonus for employees starting before September 30th, 2026.

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.
• 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 demographic and insurance information.
• Adjudicate pharmacy claims for primary, secondary, and tertiary plans and review responses for accuracy.
• Contact insurance companies to resolve third-party rejections and ensure timely shipping of medications.
• Perform outreach calls to patients or providers to reschedule deliveries if claim resolution causes shipment delays.
• Ensure copay cards are applied only to eligible patients based on criteria such as insurance type (government beneficiaries not eligible).
• Manage funding-related adjudications and serve as a liaison to the Onco360 Advocate team.
• Assist the pharmacy team with electronically adjudicated claims to reconcile delivery assessments and ensure copay payments are charged prior to shipment.
• Serve as a customer service liaison to patients regarding financial responsibility, 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, including patient confidentiality laws.
• Contribute to team efforts by accomplishing related tasks as needed.
• Conduct job responsibilities in accordance with company standards, policies, 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).
• Pharmacy/NDC medication billing, pharmacy claims resolution, PBM and 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).
• Basic math and analytical skills, intermediate typing/keyboarding skills.
• Knowledge of foundation funding and specialty pharmacy experience (desired).
• Registration with the Board of Pharmacy as required by state law (required).
• Certified Pharmacy Technician (PTCB) (desired).

Skills

• Independent worker with excellent interpersonal skills.
• Strong verbal and written communication skills.
• Ability to work efficiently to meet deadlines and be flexible.
• Detail-oriented with great time-management skills.

Benefits

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