healthcare 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>
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#LI-LS2</div>
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#LI-HYBRID</div></div></div></div><br>
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<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)

Sherloq Solutions

<div><p><b>About SHERLOQ Solutions
</b></p><p>Established in 1916, SHERLOQ began as a member-owned cooperative in Tampa, Florida. The founding mission was to facilitate the sharing of credit information, promote the equitable principles in trade and give back to the community. Over 100 years later, SHERLOQ continues as a vibrant company serving hospitals, healthcare systems, physician practices and utilities nationwide.</p><p><br>
</p><p><b>Position Summary</b></p><p>
This position will require the employee to effectively communicate between healthcare providers and health insurance payers to expedite claim resolution.</p><p></p><p><b><br>
Essential Duties and Responsibilities</b></p><ul><li>
Resolve healthcare claims through verbal or online inquiries to health insurance payers.</li><li>
Effectively navigate and utilize healthcare provider systems, billing platforms, and payer websites.
</li><li>Verify patient, insurance, billing and claim submission information for accuracy.</li><li>
Eligibility inquiries and coordination of benefits research including reaching out to the patient when necessary.</li><li>
Analyze payer denials and appropriately respond to secure claim reimbursement.</li><li>
Provide information to the Billing &amp; Appeals Specialists on claims that require written appeals.</li><li>
Track trends in payer underpayments, coding issues and denials and report to leadership for escalation.</li><li>
Recognize basic coding denials and request appropriate action for correction or dispute.</li><li>
Check insurance payments for accuracy and compliance with contract discount.</li><li>
Research missing payments and secure documents needed for posting.</li><li>
Demonstrated ability to remain patient, professional &amp; effective in high pressure and high-volume environments.</li><li>
Meet or exceed daily, weekly and monthly performance goals, deadlines and objectives.</li><li>
Perform other related duties as assigned.</li></ul><p><b>
Abilities</b></p><ul><li>
Excellent verbal and written communication skills.</li><li>
Excellent interpersonal and negotiation skills.</li><li>
Organized with attention to detail.</li><li>
Ability to read and interpret insurance explanation of benefits.</li><li>
Ability to problem solve and think critically to identify trends.</li><li>
Demonstrated proficiency in Microsoft 365 (Teams, Outlook, OneDrive, SharePoint) within a cloud-based, collaborative environment.</li></ul><p><b>
Experience and Education</b></p><ul><li>
High school graduate or equivalent required.</li><li>
Three (3) years of healthcare industry experience required.</li><li>
One (1) year of healthcare claims billing, insurance collections, coding, and/or denials management required.</li><li>
Specific healthcare payer experience may be required (e.g., Medicare or state-specific payers).</li><li>
Obtain HFMA CRCR or AAHAM CRCS accreditation within two years of employment and maintain certification in good standing.</li></ul><p>
Pay Range: $18+ per hour</p><p>
Schedule: Monday- Friday 8am-5pm</p><p><b>
We value our employees and offer a comprehensive benefits package including medical insurance, 401(k), paid time off, paid holidays, tuition reimbursement, and additional supplemental benefits.</b><br>
<br>
SHERLOQ is an Equal Opportunity Employer and considers all qualified applicants without regard to race, color, religion, sex, national origin, disability, or veteran status.</p><p>
If you feel this is the right opportunity for you, we encourage you to apply. We look forward to meeting you!</p></div>

Specialist, Insurance Revenue Cycle

CareMed Specialty Pharmacy

<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>

Pharmacy Adjudication Specialist

<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>

Progress Weight Management

<p><b>Medical Billing Specialist</b></p><p><b>Location:</b> Fargo, ND (In-Person)</p><p><b>Job Type:</b> Full-Time</p><p><b>Pay Range:</b> $18.00&ndash;$25.00 per hour</p><p><b>About the Role</b></p><p>We are seeking a detail-oriented and dependable <b>Medical Billing Specialist</b> to join our growing healthcare team in Fargo, North Dakota. This position plays a critical role in supporting the financial health of our organization by ensuring accurate claim submission, timely reimbursement, and exceptional patient service.</p><p>The ideal candidate has prior medical billing experience, strong problem-solving skills, initiative, and a collaborative work ethic. They are confident in working with insurance claims, billing processes, revenue cycle management, and EHR systems while contributing to a mission-driven healthcare organization.</p><p><b>Key Responsibilities</b></p><p><b>Claims Management &amp; Reimbursement</b></p><ul><li>Prepare, review, and submit accurate medical claims to commercial insurance carriers, Medicare, Medicaid, Tricare, and other third-party payers.</li><li>Audit claims for completeness and accuracy prior to submission.</li><li>Monitor claim status and perform follow-up on unpaid, delayed, denied, or rejected claims.</li><li>Research claim issues and coordinate appeals to maximize reimbursement.</li><li>Document all follow-up activities and claim actions within patient account records.</li></ul><p><b>Insurance Verification &amp; Eligibility</b></p><ul><li>Verify patient insurance eligibility and benefits prior to services.</li><li>Identify authorization and referral requirements when applicable.</li><li>Confirm coverage limitations and patient financial responsibility.</li></ul><p><b>Patient Billing &amp; Customer Service</b></p><ul><li>Generate and distribute patient statements.</li><li>Assist patients with billing questions, insurance explanations, account balances, and payment options.</li><li>Explain Explanation of Benefits (EOBs) and patient financial obligations in a professional manner.</li></ul><p><b>Payment Posting &amp; Account Reconciliation</b></p><ul><li>Post insurance payments, patient payments, contractual adjustments, and corrections accurately.</li><li>Reconcile account balances and investigate discrepancies.</li><li>Maintain accurate billing and payment records.</li></ul><p><b>Compliance &amp; Reporting</b></p><ul><li>Ensure compliance with HIPAA regulations and payer requirements.</li><li>Maintain confidentiality of patient information at all times.</li><li>Stay current on billing regulations, coding updates, and reimbursement guidelines.</li><li>Prepare reports and billing-related documentation as requested.</li></ul><p><b>Qualifications</b></p><p><b>Required</b></p><ul><li>High school diploma or equivalent.</li><li>Minimum 1&ndash;3 years of medical billing experience in a clinic, hospital, or healthcare billing environment.</li><li>Experience with medical billing software and Electronic Health Record (EHR) systems.</li><li>Knowledge of medical terminology and healthcare reimbursement processes.</li><li>Familiarity with ICD-10, CPT, and HCPCS coding systems.</li><li>Understanding of Medicare, Medicaid, commercial insurance, and coordination of benefits.</li><li>Strong attention to detail and organizational skills.</li><li>Excellent communication and customer service abilities.</li><li>Ability to multitask and prioritize work in a fast-paced environment.</li><li>Proficiency with computers.</li><li>Ability to maintain confidentiality and professionalism when handling sensitive information.</li></ul><p><b>Preferred</b></p><ul><li>Certified Professional Biller (CPB), Certified Billing &amp; Coding Specialist (CBCS), or similar credential.</li></ul><p><b>Benefits</b></p><ul><li>Medical, Dental &amp; Vision Insurance</li><li>Short Term Disability Insurance</li><li>Retirement</li><li>Paid Time Off (PTO)</li><li>Paid Holidays</li></ul><p>Pay: $18.00 - $25.00 per hour</p><p>Benefits:</p><ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Retirement plan</li><li>Vision insurance</li></ul><p>Work Location: In person</p>

Medical Billing Specialist

Onco360

<div><div>We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in<b> Scottsdale, AZ. </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: 8:30 am-5:00 pm MST</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><b>#Company Values: Teamwork, Respect, Integrity, Passion</b></div>
<div></div><div>#IH</div></div></div>

Pharmacy Claims Adjudication Specialist

<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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