Pharmacy Claims Adjudication Specialist

Position Overview We are seeking a Pharmacy Adjudication Specialist for our Specialty Oncology pharmacy. As our company continues to grow, we strive to hire new team members with a passion for making a difference in our patient’s lives. Full‑time position working out of the State of Connecticut. This position may work remotely. Shift times currently available: 9:00 am‑5:30 pm EST or 10:00 am‑6:30 pm EST. Starting salary from $26.00 an hour and up. Sign‑On Bonus: $5,000 for employees starting before July31,2026. Benefits Medical, Dental, Vision 401(k) with match Paid Time Off and Paid Holidaysi> Tuition Reimbursement Company‑paid life insurance and short and long‑term disability benefits Responsibilities Adjudicate pharmacy claims, review claim responses for accuracy, and 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 notifications regarding delays 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 review 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 the Onco360 Advocate team. Assist the 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 a 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. Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws. Contribute to the 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 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: 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, 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 Desired: Registration with Board of Pharmacy as required by state law; 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