Pharmacy Claims Adjudication Specialist
About the role
This organization operates a specialty oncology pharmacy designed to support community, oncology, and hematology physicians, patients, payers, and manufacturers. It addresses the complex needs involved in oncology pharmaceutical care, focusing on facilitating medication access and insurance claim processes in the specialized pharmaceutical sector. The PHARMACY CLAIMS ADJUDICATION SPECIALIST is responsible for managing the adjudication of pharmacy claims to ensure accurate and timely processing. This role plays a critical part in resolving insurance claim rejections, coordinating benefits, and communicating with patients and healthcare providers to prevent delays in medication delivery, thereby directly supporting patient care continuity.
Responsibilities
- Adjudicate pharmacy claims for primary, secondary, and tertiary plans and review responses for accuracy.
- Resolve third-party rejections and obtain overrides when appropriate.
- Conduct patient outreach regarding medication delivery delays due to insurance issues.
- Maintain accurate patient demographic and insurance information in the system.
- Ensure copay cards are applied only to eligible patients.
- Manage funding-related adjudications and collaborate with the advocacy team.
- Assist pharmacy operations in reconciling electronically adjudicated claims and copay payments.
- Serve as a liaison for patient communication concerning financial responsibilities and copay discrepancies.
- Document and submit patient refund requests when applicable.
- Comply with pharmacy safety, confidentiality, and professional standards.
- Perform additional tasks as assigned and adhere to the organization's code of conduct and applicable laws.
Requirements
- High School Diploma or GED required; Associate degree or equivalent preferred.
- Minimum 2 years of experience in a pharmacy, healthcare setting, or pharmacy claims adjudication; 3+ years preferred.
- Knowledge of pharmacy billing, claims resolution, PBM and medical contracts.
- Understanding of Medicare, Medicaid, commercial insurance, and claim rejection processes.
- Basic math, analytical skills, and intermediate typing proficiency.
- Strong communication, interpersonal skills, and ability to work independently with attention to detail.
Qualifications
- Active Connecticut Pharmacy Technician credentials required.
- Certified Pharmacy Technician certification and specialty pharmacy experience preferred.
Skills
- Strong communication and interpersonal skills.
- Ability to work independently with attention to detail.
- Basic math and analytical skills.
- Intermediate typing proficiency.
Benefits
- Medical insurance
- Dental insurance
- Vision insurance
- 401k with company match
- Paid Time Off and Paid Holidays
- Tuition reimbursement
- Company-paid life insurance and short- and long-term disability insurance
Pay
Starting salary from $26.00 an hour and up. Sign-On Bonus of $5,000 for employees starting before December 31st, 2026.