Pharmacy Claims Adjudication Specialist

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Scottsdale, AZ . This will be a Full‑Time position and a remote hybrid opportunity after an onsite training period. Shift times currently available: 8:30 am–5:00 pm MST, or 9:30 am–6:00 pm MST. Starting salary from $23.00 an hour and up. Benefits Medical, Dental, Vision 401(k) with a match Paid Time Off and Paid Holidays Tuition Reimbursement Company‑paid benefits – life; short‑term and long‑term disability 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. 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 demographics 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 delays. Ensures 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 the 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 submits requests for patient refunds when appropriate. Qualifications 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: 1+ years experience in a Pharmacy/Healthcare setting or pharmacy claims experience. Desired: 3+ years experience in a Pharmacy/Healthcare setting or pharmacy claims experience. Skills / Knowledge Required: Pharmacy/NDC medication billing, Pharmacy claims resolution, PBM and Medical contracts, knowledge 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, 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: Registration with the 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. #J-18808-Ljbffr JobRx, Inc.