Pharmacy Claims Adjudication Specialist

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Buffalo, NY
. This will be a Full-Time position. This position must be located within driving distance to our pharmacy, with a hybrid work style.

Onco
360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.

Starting salary from $21.00 an hour and up.

Sign-On Bonus: $5,000 for employees starting before February 1, 2026.

• Medical, Dental, Vision
• 401k with a match
• Paid Time Off and Paid Holidays
• Tuition Reimbursement
• Company paid benefits – life; and short and long-term disability

• 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 notification regarding any delay 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 Onco
  360 Advocate team.
• Assist 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 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.

• 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.

• Required:
  
  1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience.
• Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience.

• 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.

• 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, work efficiently to meet deadlines and be flexible, detail‑oriented, great time‑management skills.

Company Values:
Teamwork, Respect, Integrity, Passion.

• Entry level

• Full‑time

• Health Care Provider

• Pharmaceutical Manufacturing

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