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Pharmacy Claims Specialist
2 months ago
We are seeking a highly skilled Pharmacy Adjudication Specialist to join our team at Onco360 Pharmacy in Louisville, KY. This is a full-time position with two available shifts: Monday to Friday, 11:30am to 8pm EST and 9:30am - 6pm EST. The ideal candidate will be located within driving distance to our pharmacy and have a hybrid work style.
Job SummaryThe Pharmacy Adjudication Specialist will be responsible for adjudicating pharmacy claims, reviewing claim responses for accuracy, and ensuring prescription claims are adjudicated correctly according to the coordination of benefits. This role will also involve resolving third-party rejections, obtaining overrides if necessary, and notifying patients of any delays in medication delivery due to insurance claim rejections.
Key Responsibilities- Adjudicate pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and review claim responses for accuracy.
- 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 and causes shipment delays.
- Ensure copay cards are only applied to claims for eligible patients based on set criteria such as insurance type.
- 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 and collect payment if applicable.
- Education: High School Diploma or GED. Previous experience in pharmacy, medical billing, or benefits verification, pharmacy claims adjudication.
- Work Experience: 1+ years experience in a pharmacy or healthcare setting or pharmacy claims experience.
- Skills/Knowledge: 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 and Roman numerals, brand/generic names of medication, basic math and analytical skills, intermediate typing/keyboarding skills.
At Onco360, we value teamwork, respect, integrity, and passion. If you are a motivated and detail-oriented individual with a passion for pharmacy and customer service, we encourage you to apply for this exciting opportunity.
