disability claims specialist

Maine Public Employees Retirement System

<div><div><div><div><div><div><div><p>Maine Public Employees Retirement System (MainePERS) is seeking a detail-oriented and analytical Disability Specialist to oversee disability retirement and rehabilitation programs. In this role, you will evaluate disability retirement applications, review ongoing eligibility for benefits, and coordinate rehabilitation services. You will work closely with members, employers, healthcare providers, and medical review professionals to ensure fair, timely, and accurate determinations.</p><p><b>
What You'll Do</b></p><ul><li>
Evaluate disability retirement applications and continuing eligibility for benefits.</li><li>
Gather, review, and analyze medical, vocational, and employment information.</li><li>
Assess individuals' ability to perform essential job functions and evaluate reasonable accommodations.</li><li>
Issue eligibility determinations in consultation with the Medical Review Service Provider.</li><li>
Coordinate rehabilitation services and monitor program compliance.</li><li>
Communicate effectively with members, employers, healthcare providers, and other stakeholders.</li><li>
Assist with appeals and provide technical guidance on disability and rehabilitation matters.</li><li>
Represent the organization at meetings, presentations, and public outreach events.</li></ul><p><b>
What We're Looking For</b></p><ul><li>
Strong analytical and problem-solving skills.</li><li>
Excellent written and verbal communication abilities.</li><li>
Sound judgment and the ability to make timely decisions.</li><li>
A commitment to accuracy, accountability, and exceptional customer service.</li><li>
The ability to build trust and work collaboratively with diverse audiences.</li></ul><p><b>
Minimum Qualifications</b></p><ul><li>
Bachelor's degree in a related field and two years of progressively responsible administrative experience; OR</li><li>
Associate's degree in a related field and five years of complex administrative or technical experience; OR</li><li>
An equivalent combination of education and experience.</li><li>
At least one year of experience applying complex laws, regulations, policies, or procedures.</li><li>
Proficiency with Microsoft Office applications.</li></ul><p><b>
Preferred Qualifications</b></p><ul><li>
Experience evaluating medical evidence and determining eligibility for benefits or services.</li><li>
Experience in disability determination, vocational rehabilitation, insurance claims, or a related field.</li></ul><p><b>
Salary</b>: Begins at $67,787 (if annualized).</p><p><b>
Benefits:</b> We offer an outstanding benefit package including: <b>13 Paid Holidays</b>, Health Insurance, Dental Insurance (<b>fully paid</b>), Vision Care, Life Insurance, Defined Benefit Pension Plan, Deferred Compensation Plan, substantial Tuition Reimbursement, Parental leave, Generous Vacation and Sick Leave. <b>Eligible for a hybrid work schedule</b> after a successful probationary period.</p></div></div></div></div></div></div><br>
<p></p>
7:30am-4:00pm, Monday through Friday<br>
40 hours per week, 80 hours per 2-week pay period</div>

Disability Claims Specialist

Claims Specialist

Sedgwick

<div><p>By joining Sedgwick, you'll be part of something truly meaningful. It&rsquo;s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there&rsquo;s no limit to what you can achieve.
</p><p></p><p>Newsweek Recognizes Sedgwick as America&rsquo;s Greatest Workplaces National Top Companies
</p><p>Certified as a Great Place to Work&reg;
</p><p>Fortune Best Workplaces in Financial Services &amp; Insurance
</p><p></p>Disability Representative Sr
<p></p><p><b>Our teams connect!
</b></p><p><b>We collaborate onsite and have a hybrid work arrangement.
</b><br>
<b>All candidates must live near one of our centers of excellence:<br>
</b></p><p></p><p><b>Cedar Rapids, IA </b>: 333 1st Street SE Ste. 200 Cedar Rapids IA 52401
</p><p><b>Chicago, IL : </b>175 W. Jackson Blvd. 12th Fl. Chicago IL 60604
</p><p></p><p><b>PRIMARY PURPOSE </b>: Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, thoroughly reviews contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors.
</p><p></p><p><b>ESSENTIAL FUNCTIONS and RESPONSIBILITIES
</b></p><ul><li>Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan.
</li><li>Reviews and analyzes complex medical information (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
</li><li>Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
</li><li>Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed.
</li><li>Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
</li><li>Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system.
</li><li>Communicates with the claimants&rsquo; providers to set expectations regarding return to work.
</li><li>Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
</li><li>Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and/or claims system.
</li><li>Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
</li><li>Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
</li><li>Negotiates return to work with or without job accommodations via the claimant&rsquo;s physician and employer.
</li><li>Refers cases to team lead and clinical case management for additional review when appropriate.
</li><li>Maintains professional client relationships and provides excellent customer service.
</li><li>Meets the organization&rsquo;s quality program(s) minimum requirements.
</li></ul><p></p><p><b>ADDITIONAL FUNCTIONS and RESPONSIBILITIES
</b></p><ul><li>Performs other duties as assigned.
</li></ul><p></p><p><b>QUALIFICATIONS
</b></p><p></p><p><b>Education &amp; Licensing
</b><br>
High School diploma or GED required. Bachelor's degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.
</p><p></p><p><b>Experience
</b><br>
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.
</p><p></p><p><b>Skills &amp; Knowledge
</b></p><ul><li>Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
</li><li>Knowledge of state and federal FMLA regulations
</li><li>Working knowledge of medical terminology and duration management
</li><li>Excellent oral and written communication, including presentation skills
</li><li>Proficient computer skills including working knowledge of Microsoft Office
</li><li>Analytical, interpretive, and critical thinking skills
</li><li>Ability to manage ambiguity
</li><li>Strong organizational and multitasking skills
</li><li>Ability to work in a team environment
</li><li>Ability to meet or exceed performance competencies as required by program
</li><li>Effective decision-making and negotiation skills
</li><li>Ability to exercise judgement autonomously within established procedures
</li></ul><p></p><p><b>WORK ENVIRONMENT
</b><br>
When applicable and appropriate, consideration will be given to reasonable accommodations.
</p><p></p><p><b>Mental </b><b>: </b>Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
</p><p></p><p><b>Physical </b><b>: </b>Ability to sit at a desk for extended periods while operating a computer and phone system. Travel as required.
</p><p></p><p><b>Auditory/Visual </b><b>: </b>Hearing, vision and talking
</p><p></p><p>As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $21.00 - $23.00. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.
</p><p></p><p>The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
</p><p></p><p>Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
</p><p></p><h2 class="jobSectionHeader"><b>If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.</b></h2></div>

Disability Representative Sr

State of Florida

<div><p>Requisition No: 876653</p>
<p>Agency: Department of Health</p>
<p>Working Title: OPS MEDICAL DISABILITY EXAMINER - 64858446</p>
 <p>Pay Plan: Temp</p>
<p>Position Number: 64858446</p>
<p>Salary: $22.00 Hourly</p>
<p>Posting Closing Date: 06/21/2026</p>
<p><b>Total Compensation Estimator </b><b>Tool</b></p>
<p><b>DEPARTMENT OF HEALTH</b></p>
<p>DIVISION OF DISABILITY DETERMINATIONS</p>
<p><b>OPEN COMPETITIVE OPPORTUNITY</b></p>
<p><b>POSSIBLE MULTI-HIRE OPPORTUNITY</b></p>
<p><b>THIS IS AN OPS POSITION</b></p>
<p><b>TITLE: OPS CLAIMS ADJUSTERS, EXAMINERS AND INVESTIGATORS</b> <b>MEDICAL DISABILITY EXAMINER</b></p>
<p><b>POSITION LOCATION: MIAMI / DADE COUNTY</b></p>
<p><b>POSITION #: 64858446</b></p>
<p><b>SALARY: $22.00 Per hour</b></p>
<p><b>Your Specific Responsibilities:</b></p>
<p>This is entry level professional work researching, developing, compiling, analyzing, and rendering independent decisions relative to Social Security Disability Insurance, Supplemental Security Income and/or Medically Needy disability claims filed in the State of Florida. Training is provided on relevant policy, medical review and vocational evaluation. Potential advancement based on successful performance of job duties.</p>
<p>As a key member of the team, you must be able to communicate effectively with team members and the public. You must be able to operate successfully in a demanding environment, manage multiple tasks, and work independently. We are looking for people who are detailed-oriented, have critical thinking skills, understand basic math, and are able to work in a Windows-based computer environment.</p>
<p>Electronic Case Management - All work is conducted utilizing multiple computer screens and typed case notes. Appropriate transactional inputs process cases from beginning to closure, reviewing computer generated alerts to ensure timely processing. Competencies required: Written communication skills, organizational abilities, and basic computer skills required: Maintains records and other reading materials related to services or benefits. Plans, organizes and coordinates work assignments.</p>
<p>Verbal Communication - Utilizes effective verbal communication skills and telephone techniques to develop and/or establish necessary factual medical and vocational documentation.</p>
<p>Evaluates a variety of documents to determine their evidentiary sufficiency for decision-making purposes. Evaluates data for accuracy and completion.</p>
<p>Authorizes purchase of specialized medical or psychological diagnostic services, when appropriate, for the purpose of documenting the severity of impairment.</p>
<p>Secures medical evidence of record needed to document the presence of &quot;disabling&quot; or &quot;not disabling&quot; impairments. Competencies: Identifies errors or problems and takes appropriate action. Conducts fact -finding research.</p>
<p>Renders a formal decision of disability based on evidentiary requirements of Social Security law rules and regulations. Competencies: Understands and applies rules, regulations, policies and procedures relating to services and benefits.</p><br>
<p></p><p><b>Required Knowledge, Skills, and Abilities:</b></p>
<p>Knowledge of the principles and techniques of effective communication.</p>
<p>Ability to collect, evaluate and analyze data relating to disability benefits.</p>
<p>Ability to understand and apply applicable rules, regulations, policies and procedures relating to disability benefits.</p>
<p>Ability to evaluate data for accuracy and completion.</p>
<p>Ability to identify errors or problems and take appropriate corrective action.</p>
<p>Ability to compose correspondence.</p>
<p>Ability to organize data into logical format.</p>
<p>Ability to work independently.</p>
<p>Ability to conduct fact-finding research.</p>
<p>Ability to utilize problem-solving techniques.</p>
<p>Ability to plan, organize and coordinate work assignments.</p>
<p>Ability to communicate effectively.</p>
<p>Ability to establish and maintain effective working relationships with others.</p><br>
<p></p><p><b>Preferred Qualifications:</b></p>
<p>Preference will be given to applicants with a bachelor&rsquo;s degree (or an equivalent combination of education and work experience - such as an Associate&rsquo;s degree with two years of work experience, or a high school diploma with four years of work experience), in one or more of the following fields:</p><br>
<p></p><p>1) Managing a caseload for an insurance, disability, vocational, social work or government program</p>
<p>2) Determining initial or continued eligibility of claims, based on rules and regulations</p>
<p>3) Experience working in a medical or vocational field</p><br>
<p></p><p><b>Florida Department of Health Mission, Vision, and Values:</b></p>
<p>Mission:</p>
<p>To protect, promote &amp; improve the health of all people in Florida through integrated state, county &amp; community efforts.</p>
<p>Vision:</p>
<p>To be the <i>Healthiest </i>State in the Nation.</p>
<p>Values:</p>
<p><b>I </b>nnovation: We search for creative solutions and manage resources wisely.</p>
<p><b>C</b> ollaboration: We use teamwork to achieve common goals &amp; solve problems.</p>
<p><b>A</b> ccountability: We perform with integrity &amp; respect.</p>
<p><b>R</b> esponsiveness: We achieve our mission by serving our customers &amp; engaging our partners.</p>
<p><b>E</b> xcellence: We promote quality outcomes through learning &amp; continuous performance improvement.</p>
<p><b>Where You Will Work:</b></p>
<p>Miami</p>
<p><b>The Benefits of Working for the State of Florida:</b></p>
<p>Working for the State of Florida is more than a paycheck. The State&rsquo;s total compensation package for employees features a highly competitive set of employee benefits including:</p>
<ul><li>State Group Insurance coverage options, including health, life, dental, vision, and other supplemental insurance options;</li>
<li>Retirement plan options, including employer contributions
<br>
(</li>
</ul><ul><li>Flexible Spending Accounts;</li>
</ul><p>And more!</p>
<p>For a more complete list of benefits, including monthly costs, visit www.mybenefits.myflorida.com.</p><br>
<p></p><p><b>Please be advised:</b></p><br>
<p></p><p>Your responses to qualifying questions for this position must be verifiable by documentation provided through the electronic application process.</p><br>
<p></p><p>This position requires a security background check and participation in direct deposit.</p><br>
<p></p><p><b><i>Your conditional job offer and access to Social Security Administration&rsquo;s (SSA&rsquo;s) systems, data, information, and/or premises are contingent upon you passing the SSA suitability process.</i></b></p>
<ul><li><b><i>Note: This covers the preliminary screening (pre-screen) and the final background adjudication stage of the suitability process.</i></b></li></ul><br>
<p></p><p>Any misrepresentations or omissions will disqualify you from employment consideration. Note: You will be required to provide your Social Security Number (SSN) in order to conduct this background check Successful completion of a drug test is a condition of employment for safety-sensitive positions.</p><br>
<p></p><p>Male applicants born on or after October 1, 1962, will not be eligible for hire or promotion unless they are registered with the Selective Services System (SSS) before their 26th birthday, or have a Letter of Registration Exemption from the SSS.</p><br>
<p></p><p>If you are a retiree of the Florida Retirement System (FRS), please check with the FRS on how your current benefits will be affected if you are re-employed with the State of Florida. Your current retirement benefits may be canceled, suspended or deemed ineligible depending upon the date of your retirement.</p><br>
<p></p><p>The successful candidate will be required to complete the Form I-9 and that information will be verified using the E-Verify system. E-Verify is operated by the Department of Homeland Security in partnership with the Social Security Administration to verify employment eligibility.<br>
</p><p></p><p>Incumbents may be required to perform emergency duty before, during, and/or beyond normal work hours or days.</p><br>
<p></p><p>All Florida Department of Health positions require the incumbent to be able to learn and communicate effectively, orally and in writing, in English. Applicants who do not meet this requirement will not be considered.</p><br>
<p></p><p>The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer and does not tolerate discrimination or violence in the workplace.</p><br>
<p></p><p>Applicants requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-877-562-7287). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.</p><br>
<p></p><p>The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.</p><br>
<p></p><p>Florida has the third largest population of veterans in the nation with more than 1.5 million service men and women. The Florida Department of Health (department) is committed to serving members of the United States Armed Forces, veterans and their families by encouraging them to apply for vacancies that fit their area of knowledge and/or expertise. Through the Department's VALOR program, which expedites licensing for military veterans, the Department also waives initial licensing and application fees for military veterans who apply for a health care professional license within 60 months of an honorable discharge. These initiatives help ensure that the transition from military service into the workforce is as smooth as possible and reflects our appreciation for the dedication devoted to protecting our country.
</p><p>The State of Florida is an Equal Opportunity Employer/Affirmative Action Employer, and does not tolerate discrimination or violence in the workplace.</p>
<p>Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.</p>
<p>The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.</p>
<p>Candidates requiring a reasonable accommodation, as defined by the Americans with Disabilities Act, must notify the agency hiring authority and/or People First Service Center (1-866-663-4735). Notification to the hiring authority must be made in advance to allow sufficient time to provide the accommodation.</p>
<p>The State of Florida supports a Drug-Free workplace. All employees are subject to reasonable suspicion drug testing in accordance with Section 112.0455, F.S., Drug-Free Workplace Act.</p>
<div><div><div><div>Location:
MIAMI, FL, US, 33186<br>
</div></div></div></div><p><br>
<b>Nearest Major Market: </b>Miami</p></div>

OPS MEDICAL DISABILITY EXAMINER - 64858446

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

<div><div>We are seeking a Pharmacy Adjudication Specialist at our <b>CareMed Specialty Pharmacy</b> in<b> New Hyde Park, NY. </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 EST</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>

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>

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