Pharmacy Claims Adjudication Specialist

Position

Pharmacy Claims Adjudication Specialist

Location

Waltham, MA – must be located within driving distance to our pharmacy with a hybrid work style.

Job Id

5093

Openings

1

Salary

Starting salary from $26.00 an hour and up.

Benefits

• 401(k) with match
• Paid Time Off and Paid Holidays
• Tuition Reimbursement
• Company‑paid benefits – life; and short and long‑term disability

Responsibilities

The Pharmacy Adjudication Specialist will:

• Adjudicate pharmacy claims, review claim responses for accuracy, and ensure prescription claims are adjudicated correctly according to coordination of benefits.
• Resolve any third‑party rejections, obtain overrides when appropriate, and ensure timely shipping of medications.
• Conduct patient outreach notifications regarding delays in medication delivery due to insurance claim rejections.
• Respond to health‑care providers and patients’ pharmacy needs as first‑point resolution, answering questions and requests.
• Provide thorough, accurate, and timely responses to requests from pharmacy operations, providers, or patients regarding active claims information.
• Ensure complete and accurate patient setup in CPR+ system, including demographic and insurance information.
• 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 medication deliveries if claim resolution cannot be completed by ship date.
• 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 serve as liaison to the Onco360 Advocate team.
• Assist pharmacy team with management of electronically adjudicated claims to reconcile all prescription delivery assessments and charge copay payments prior to shipment.
• Serve as customer‑service liaison to patients regarding financial responsibility prior to shipments, contact patients to communicate any copay discrepancy and collect payment if applicable.
• Document and submit requests for patient refunds when appropriate.

Qualifications

• Education/Learning Experience
  • Required: High School Diploma or GED. Previous experience in pharmacy, medical billing, benefits verification, or pharmacy claims adjudication.
  • Desired: Associate degree or equivalent from a two‑year program or technical school; Certified Pharmacy Technician; specialty pharmacy experience.
• Work Experience
  • Required: 1+ year experience in a pharmacy or healthcare setting or pharmacy claims experience.
  • Desired: 3+ years experience in a pharmacy or 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
  • Required: Registration with Board of Pharmacy as required by state law.
  • Desired: Certified Pharmacy Technician (PTCB).
• Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently and efficiently to meet deadlines and be flexible, detail‑oriented, great time‑management skills.