claims adjudicator

Claims Specialist

Gainwell Technologies LLC

<div><div><div><div><div><p>Claims Specialist- Anchorage, AK (Hybrid)
</p></div></div></div></div><div><div><div><div><b>Date: </b>Jun 8, 2026
</div></div></div></div><div><div><div><div><b>Location:
</b>Any city, AK, US, 99999
</div></div></div></div><div><div><div><div><b>Req ID: </b>36193
</div></div></div></div><div><div><div><div><b>Work Mode: </b>Virtual (Exception only)
</div></div></div></div><div></div><div><div><div><div><div>Great companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You&rsquo;ll have an incredible opportunity to grow your career in a company that values your contributions and puts a premium on work flexibility, learning, and career development.</div><div></div><div><div><div><div><b><br>
Summary</b></div>
</div><div><div>
As <b>Claims Specialist- Anchorage, AK (Hybrid)</b>, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve &mdash; a community&rsquo;s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare&rsquo;s biggest challenges. Here are the details on this position. HMS is hiring Claims Specialists to support our Alaska account. These positions processes moderately complex claims for our Alaska Medicaid client. They will make decisions on payment of medical claims using the existing policy and rules to ensure accurate and timely completion.</div></div></div><div></div><div><div><div><b><br>
Your role in our mission</b></div>
</div><div><ul><li>Review and research suspended medical claims and adjudicate them per DHS policy.</li>
<li>Refer claims to Utilization Review and Provider Services units.</li>
<li>Maintain necessary documentation.</li>
<li>Participate in meetings as necessary.</li>
<li>Participate in process improvement sessions.</li>
<li>Train as a back-up for other areas, such as document control, courier, and customer service desk.</li>
<li>Other duties as assigned</li>
</ul></div></div><div><div><div><b>What we're looking for</b></div>
</div><div><ul><li>Ability to work both independently and as part of a team.</li>
<li>Strong communication skills with the ability to communicate clearly and effectively in writing and verbally.</li>
<li>Ability to access and retrieve information using a PC.</li>
<li>Intermediate understanding of Microsoft Office products.</li>
<li>Organizational skills to balance and prioritize work, and analytical and problem-solving skills.</li>
</ul></div></div><div><div><div><b>What you should expect in this role</b></div>
</div><div><ul><li>Hybrid role with ability to work in the Anchorage, AK office preferred, with the possibility of working remotely from another state for the right candidate. The person will need to work Alaska Time hours.</li></ul><br>
<div></div>
<div>
#LI-LS2</div>
<div>
#LI-HYBRID</div></div></div></div><br>
<div></div>
<div>
The pay range for this position is $37,500.00 - $53,500.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You&rsquo;ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.</div><br>
<div></div>
<div>
We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You&rsquo;ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.</div><br>
<div></div>
<div><i>
Gainwell Technologies </i><i>is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. </i><i>Gainwell Technologies defines &ldquo;wages&rdquo; and &ldquo;wage rates&rdquo; to include &ldquo;all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.</i></div></div></div></div></div></div><p></p>

Claims Specialist- Anchorage, AK (Hybrid)

Imagenet, LLC

<div><p><b>Claims Adjudication Manager</b></p>
<p><i>
U.S.-Based Operational Leader Overseeing Philippines Claims Adjudication</i></p><p></p><p><br>
Work Setup: <b>Remote</b></p>
<p>
Reports To: <b>SVP Operations</b></p>
<p>
Direct Oversight: <b>Philippines-based claims adjudication team (examiners, auditors, team leads)</b></p>
<p>
Hours: <b>Pacific Time Zone: Core overlap with Philippines business hours required; evening calls for client/offshore alignment</b></p><p></p><p><b><br>
Role Summary</b></p>
<p>
Imagenet is seeking an experienced, U.S.-based Claims Adjudication Manager to provide hands-on operational leadership for a claims adjudication account, which is delivered through our wholly owned global delivery center in the Philippines. This is a player-coach role for a seasoned claims subject-matter expert (SME) who can bridge U.S. client expectations and offshore delivery &mdash; directly strengthening quality, throughput, reporting accuracy, and client-facing credibility.</p><p></p><p><br>
The successful candidate combines deep adjudication expertise in both hospital (facility) and professional claims with proven experience leading and developing offshore claims teams. They will serve as the senior operational point of contact for the client, set the standard for adjudication accuracy, and build the coaching, audit, and documentation infrastructure needed to deliver consistent, high-quality outcomes at scale. They will not hesitate to role up their sleeves and dive into production and quality.</p><p></p><p><b><br>
Key Responsibilities</b></p>
<p><b>
Operational Leadership (Onshore Lead for Offshore Delivery)</b></p>
<ul>
<li>Provide day-to-day operational leadership for the Philippines-based adjudication team (examiners, auditors, and team leads), working across time zones to direct priorities and remove blockers.</li>
<li>Serve as the hands-on claims SME for the campaign &mdash; personally adjudicating complex or escalated claims and modeling correct handling for the team.</li>
<li>Drive accuracy, productivity, quality, and service-level goals; translate client requirements into clear, executable operating procedures.</li>
<li>Partner with the offshore manager and team leads to strengthen communication, information flow, and consistency of execution.</li>
</ul>
<p><b>Client Engagement &amp; Single Point of Contact</b></p>
<ul>
<li>Act as the senior operational single point of contact (SPOC) for the client, consolidating guidance from multiple client stakeholders into one consistent set of directives for the delivery team.</li>
<li>Lead client working sessions, escalations, and operational updates with confidence and credibility; provide clear written and verbal updates on performance, quality, and improvement actions.</li>
<li>Manage frequently changing client requirements &mdash; capturing, sequencing, and operationalizing new directives without disrupting production.</li>
</ul>
<p><b>Quality, Coaching &amp; Audit</b></p>
<ul>
<li>Own the quality program: reduce repeat errors, identify root causes, and close coaching gaps through targeted, SME-led feedback.</li>
<li>Align coaching responsibilities with subject-matter expertise; design and lead calibration sessions between examiners and auditors.</li>
<li>Assess auditor capability and set audit-throughput targets that balance thoroughness with release timelines.</li>
</ul>
<p><b>Reporting &amp; Production Validation</b></p>
<ul>
<li>Oversee validation of production reporting; partner with the business analyst and client to resolve reporting discrepancies (e.g., over- or under-counting) and establish a trusted tracking methodology.</li>
<li>Use data to identify capacity, monitor service levels, and demonstrate measurable improvement to the client.</li>
</ul>
<p><b>Documentation &amp; Knowledge Management</b></p>
<ul>
<li>Establish and maintain a centralized documentation and knowledge-management process for client directives, reducing reliance on individual knowledge.</li>
<li>Ensure source documentation is centralized and current so that AI-assisted retrieval and other enablement tools deliver reliable answers.</li>
</ul>
<p><b>Workforce &amp; Cross-Functional Collaboration</b></p>
<ul>
<li>Partner with HR and recruiting to accelerate hiring, rebuild the candidate pipeline, and stabilize staffing levels.</li>
<li>Collaborate with QA, training, workforce management, infrastructure/IT (including connectivity and latency monitoring for remote staff), and client services to support execution.</li>
<li>Coordinate with consultants, business analysts, and transition partners during onboarding and ramp activities.</li></ul><br>
<p></p>
<p><b>
Must-Have Qualifications</b></p>
<ul>
<li><b>6+ years of U.S. healthcare claims adjudication experience, with hands-on expertise in BOTH hospital/facility (UB-04) and professional (CMS-1500/HCFA) claims.</b></li>
<li><b>3+ years leading claims teams (managing 30&ndash;40+ examiners/auditors, directly or through team leads), ideally including offshore or BPO/shared-services teams.</b></li>
<li>Demonstrated ability to serve as a client-facing operational leader &mdash; running working sessions, owning escalations, and building client trust.</li>
<li>Strong command of claims workflows, medical terminology, coding concepts, benefits, and payer/provider processes.</li>
<li>Proven track record managing productivity, quality, service levels, and team performance in a metrics-driven environment.</li>
<li>Experience coaching examiners and reducing error rates through structured quality and calibration programs.</li>
<li>Excellent written and verbal communication; able to work effectively across cultures and time zones.</li>
<li>Strong analytical and problem-solving skills, including working with production and quality data.</li></ul><br>
<p></p>
<p><b>
Preferred Qualifications</b></p>
<ul>
<li>Experience overseeing or supporting Philippines-based or other offshore healthcare claims operations.</li>
<li>Experience supporting U.S. health plans, TPAs, healthcare BPOs, or shared-services operations.</li>
<li>Exposure to payment review, denials, appeals, or related claims functions.</li>
<li>Experience building documentation/SOP libraries and knowledge-management processes.</li>
<li>Exposure to process improvement, automation, or digital-transformation initiatives (including AI-assisted enablement tools).</li>
<li>Familiarity with claims platforms and reporting validation.</li></ul><br>
<p></p>
<p><b>
Key Competencies</b></p>
<ul>
<li>Hands-on claims adjudication expertise (hospital + professional)</li>
<li>Operational leadership of distributed / offshore teams</li>
<li>Client and stakeholder communication; single point of contact</li>
<li>Quality, coaching, and audit calibration</li>
<li>Analytical thinking, reporting validation, and problem-solving</li>
<li>Continuous improvement and cross-functional collaboration</li></ul><br>
<p></p>
<p><b>
Company Overview</b></p>
<p>
Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services &mdash; including digital transformation, claims adjudication, and member and provider engagement services &mdash; acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with their members and providers.</p><p></p><p><br>
The company currently serves over 70 health plans, processing millions of claims and the related structured and unstructured data elements within those claims annually. Imagenet has also developed an innovative workflow technology platform, JetStream&trade;, to support traceability, governance, and automation of claims operations for its clients.</p><p></p><p><br>
Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S., and has a wholly owned global delivery center in the Philippines.</p></div>

Claims Adjudication Manager

CareMed Specialty Pharmacy

<div><div>We are seeking a Pharmacy Adjudication Specialist at our <b>CareMed Specialty Pharmacy</b> in<b> Waltham, MA. </b>This will be a Full-Time position.<b> </b>This is a <b>remote hybrid opportunity, after onsite training period.</b></div>
<div></div><div><div><b>Shift time currently available: 9:00 am-5:30 pm CST</b></div>
<div></div><div><b>Starting salary from $26.00 an hour and up</b></div>
</div><div></div><div><b>Sign-On Bonus: </b><b>$5,000 for employees starting before July 31, 2026.</b></div>
<div></div><div>We offer a variety of benefits including:</div>
<ul><li>Medical; Dental; Vision</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Company paid benefits &ndash; life; and short and long-term disability</li>
</ul><div><b>Pharmacy Adjudication </b><b>Specialist Major Responsibilities:</b></div>
<div>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</div>
<div></div><div>Pharmacy Adjudication Specialists at CareMed...</div>
<ul><li>Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.</li>
<li>Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information.</li>
<li>Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.</li>
<li>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.</li>
<li>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</li>
<li>Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)</li>
<li>Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.</li>
<li>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.</li>
<li>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.</li>
<li>Documents and submit requests for Patient Refunds when appropriate.</li>
<li>Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws.</li>
<li>Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.</li>
<li>Conducts job responsibilities in accordance with the standards set out in the Company&rsquo;s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.</li>
</ul><div>Pharmacy Adjudication Specialist Qualifications and Responsibilities...</div>
<div><ul><li>Education/Learning Experience
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication</li>
<li>Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Work Experience
<ul><li>Required: 1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
<li>Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
</ul></li></ul><ul><li>Skills/Knowledge
<ul><li>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, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills</li>
<li>Desired: Knowledge of Foundation Funding, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Licenses/Certifications
<ul><li>Required: Registration with Board of Pharmacy as required by state law</li>
<li>Desired: Certified Pharmacy Technician (PTCB)</li>
</ul></li></ul><ul><li>Behavior Competencies
<ul><li>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</li>
</ul></li></ul><div><b>#Company Values: Teamwork, Respect, Integrity, Passion</b></div></div></div><div></div>

Pharmacy Adjudication Specialist

MCS HEALTHCARE HOLDINGS, LLC

<div><p><b>Analista de Reclamaciones III</b></p><p><br>
Regular</p><p>
Non-Exempt</p><p></p><p><b><br>
GENERAL DESCRIPTION</b></p><p>
Analyzes, processes, and adjudicates all types of complex claims submitted in Centers for Medicare and Medicaid Services Form 1500 (CMS‑1500) and Uniform Billing Form 04 (UB‑04) formats, applying the highest level of analytical judgment to determine appropriate payment or denial. This includes the evaluation of adjustments, member reimbursements, grievances, reconciliations, Coordination of Benefits (COB), United States claims, non‑participating provider claims, recoveries, reinsurance, life insurance claims, and other specialized transactions. Requests additional information, when necessary, in accordance with applicable benefits and policy requirements, and within the maximum adjudication authority limit established by current policy and procedure.</p><p><b>
ESSENTIAL FUNCTIONS</b></p><ul><li>Processes complex claims, including adjustments, COB, samplings, United States claims, non‑participating provider claims, grievances, member reimbursements, multiple categories of adjustments, reconciliations, recoveries, reinsurance, and life insurance claims, among other specialized transactions.</li><li>Evaluates and resolves claims referred from prior authorization levels and determines when analyzed claims require additional support, coordination, or intervention from other departments.</li><li>Refers claims and/or adjustments to the necessary departments to obtain additional information, support outreach efforts, or secure the required approvals for payment adjudication or denial decisions.</li><li>Reports any evidence of unusual utilization patterns, suspected attempted fraud, or irregular claim activity detected during the adjudication process to the appropriate department and immediate supervisor.</li><li>Reports to the immediate supervisor any evidence of deficiencies in system configuration, contract coverage setup, or provider agreement discrepancies identified during claim adjudication.</li><li>Reports any identified errors in payment or denial patterns to the appropriate department and the immediate supervisor to ensure prompt correction and system integrity.</li><li>Executes the average number of claims established by the company (subject to change), maintaining required financial accuracy and compliance with current policies and procedures.</li><li>Complies with and continuously update their individual productivity report as required by departmental guidelines.</li><li>Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.</li><li>May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.</li></ul><p><b>
MINIMUM QUALIFICATIONS</b></p><p><b>
Education and Experience: </b>Bachelor's Degree. At least two (2) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.</p><p><b>
OR</b></p><p><b>
Education and Experience: </b>Associate's Degree or at least sixty to sixty-four (60-64) approved college credits. At least three (3) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.</p><p><b>
OR</b></p><p><b>
Education and Experience: </b>High School Diploma or Technical Course. At least four (4) years of experience in claims processing and adjudication, applying payment policies, fee schedules, and coding guidelines, or in a Provider Call Center in the Health Insurance Industry.</p><p><b>
&quot;Proven experience may be replaced by previously established requirements.&quot;</b></p><p><b>
Certifications/Licenses: </b>N/A</p><p><b>
Other: </b>Expertise in managing and interpreting the Current Procedural Terminology, Fourth Edition (CPT‑4), International Classification of Diseases, Tenth Revision (ICD‑10), and Healthcare Common Procedure Coding System (HCPCS) coding manuals to ensure accurate claim adjudication and processing. Knowledge of payment rules, medical terminology, and standardized healthcare coding systems.</p><p><b>
Languages:</b><br>
Spanish &ndash; Intermediate (comprehensive, writing, and verbal)<br>
English &ndash; Intermediate (comprehensive, writing, and verbal)</p><p></p><p><b><br>
&ldquo;We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.&rdquo;</b></p></div>

Analista de Reclamaciones III

Onco360

<div><div>We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in <b>Buffalo, NY. </b>This will be a Full-Time position.<b> This position must be located within driving distance to our pharmacy, with a hybrid work style.</b></div>
<div></div><div><div><b>Shift times currently available: 10:00 am to 6:30 pm EST</b></div>
<div></div><div>Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.</div>
</div>
<div></div><div><b>Starting salary from $23.00 an hour and up</b></div>
<div><b>Sign-On Bonus: </b><b>$5,000 for employees starting before July 31, 2026.</b></div>
<div></div><div>We offer a variety of benefits including:</div>
<ul><li>Medical; Dental; Vision</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Company paid benefits &ndash; life; and short and long-term disability</li>
</ul><div><b>Pharmacy Adjudication </b><b>Specialist Major Responsibilities:</b></div>
<div>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</div>
<div></div><div>Pharmacy Adjudication Specialists at Onco360...</div>
<ul><li>Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.</li>
<li>Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information..</li>
<li>Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.</li>
<li>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.</li>
<li>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</li>
<li>Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)</li>
<li>Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.</li>
<li>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.</li>
<li>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.</li>
<li>Documents and submit requests for Patient Refunds when appropriate.</li>
<li>Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws.</li>
<li>Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.</li>
<li>Conducts job responsibilities in accordance with the standards set out in the Company&rsquo;s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.</li>
</ul><div>Pharmacy Adjudication Specialist Qualifications and Responsibilities...</div>
<div><ul><li>Education/Learning Experience
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication</li>
<li>Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Work Experience
<ul><li>Required: 2+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
<li>Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
</ul></li></ul><ul><li>Skills/Knowledge
<ul><li>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, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills</li>
<li>Desired: Knowledge of Foundation Funding, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Licenses/Certifications
<ul><li>Required: Registration with Board of Pharmacy as required by state law</li>
<li>Desired: Certified Pharmacy Technician (PTCB)</li>
</ul></li></ul><ul><li>Behavior Competencies
<ul><li>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</li></ul></li></ul></div></div>

Pharmacy Claims Adjudication Specialist

<div><div>We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in <b>Waltham, MA. </b>This will be a Full-Time position.<b> This position must be located within driving distance to our pharmacy, with a hybrid work style.</b></div>
<div></div><div><b>Shift times currently available: 10:00am-6:30 pm EST</b></div>
<div></div><div>Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.</div>
<div></div><div><b>Starting salary from $26.00 an hour and up</b></div>
<div><b>Sign-On Bonus: </b><b>$5,000 for employees starting before July 31, 2026.</b></div>
<div></div><div>We offer a variety of benefits including:</div>
<ul><li>Medical; Dental; Vision</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Company paid benefits &ndash; life; and short and long-term disability</li>
</ul><div><b>Pharmacy Adjudication </b><b>Specialist Major Responsibilities:</b></div>
<div>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</div>
<div></div><div>Pharmacy Adjudication Specialists at Onco360...</div>
<ul><li>Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.</li>
<li>Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information..</li>
<li>Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.</li>
<li>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.</li>
<li>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</li>
<li>Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)</li>
<li>Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.</li>
<li>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.</li>
<li>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.</li>
<li>Documenst and submit requests for Patient Refunds when appropriate.</li>
<li>Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws.</li>
<li>Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.</li>
<li>Conducts job responsibilities in accordance with the standards set out in the Company&rsquo;s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.</li>
</ul><div>Pharmacy Adjudication Specialist Qualifications and Responsibilities...</div>
<div><ul><li>Education/Learning Experience
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication</li>
<li>Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Work Experience
<ul><li>Required: 2+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
<li>Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
</ul></li></ul><ul><li>Skills/Knowledge
<ul><li>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, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills</li>
<li>Desired: Knowledge of Foundation Funding, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Licenses/Certifications
<ul><li>Required: Registration with Board of Pharmacy as required by state law</li>
<li>Desired: Certified Pharmacy Technician (PTCB)</li>
</ul></li></ul><ul><li>Behavior Competencies
<ul><li>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</li></ul></li></ul></div></div>

Search 785+ Claims adjudicator jobs near you this June. New roles added regularly across leading industries. Apply today.

785 claims adjudicator jobs Near Me

Claims Specialist

Claims Specialist- Anchorage, AK (Hybrid)

Claims Adjudication Manager

Pharmacy Adjudication Specialist

Analista de Reclamaciones III

Pharmacy Claims Adjudication Specialist

Pharmacy Claims Adjudication Specialist