What are the responsibilities and job description for the Manager - Pharmacy Adjudication position at Onco360?
Onco360 Pharmacy has a need for qualified candidates to fill our role of Pharmacy Adjudication Manager at our Louisville, KY location. This is an excellent opportunity to join our company and help with our expanding Specialty Pharmacy program! This is a full-time position, Monday to Friday 8:00am-4:30pm- some weekends as needed.
Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.
A career with us is more than just a job. It's an opportunity to connect and care for our patients, providers, communities and each other. We attract extraordinary people who have a strong desire to live our mission - to better the lives of those battling cancer and rare diseases. Compassion is more important than numbers. We value teamwork, respect, integrity, and passion.
We succeed when you do, and our company and management team work hard to foster an environment that provides you with opportunities for both professional and personal growth.
Salary starting at $64k and up depending on experience
We offer a variety of benefits including:
- Medical; Dental; Vision
- 401k with a match
- Paid Time Off and Paid Holidays
- Quarterly Incentive Bonuses
- Tuition Reimbursement
- Company paid benefits – life insurance; and short and long-term disability
The Pharmacy Adjudication Manager is responsible for oversight of activities relating to all aspects of pharmacy
claims adjudication, accuracy of pharmacy claims, resolution of third-party rejections, coordination of benefits, and
patient outreach regarding any delay in medication delivery due to insurance claim rejections. This role requires
advanced program knowledge and will provide quality control by routinely examining cases completed by team
members, review of adjudicated claims, and operations process reviews
claims adjudication, accuracy of pharmacy claims, resolution of third-party rejections, coordination of benefits, and
patient outreach regarding any delay in medication delivery due to insurance claim rejections. This role requires
advanced program knowledge and will provide quality control by routinely examining cases completed by team
members, review of adjudicated claims, and operations process reviews
Adjudication Manager Essential Functions:
- Supervises adjudication staff in a leadership role to maintain a positive working environment by creating synergy and teamwork to minimize employee relations issues and reduce turnover. Communicates effectively across pharmacy and/or corporate teams and with patients, and successfully resolves issues.
- Assists Director of Pharmacy Operations in day-to-day pharmacy operations and in implementing new procedures to ensure that the accurate and timely dispensing of quality pharmacy services is consistently delivered to all patients using effective service leadership and customer skills.
- Works with pharmacy management to recruit, select, hire, orientate, develop, and train new associates. On an ongoing basis, evaluates, coaches, and utilizes performance management practices to motivate and set expectations for adjudication staff. In collaboration with management, drafts and delivers effective corrective action plans and disciplinary action to technicians performing at substandard levels.
- Manages and reports on activity of vertical team members, including monitoring of daily workflow, Pulse reporting, and productivity trends over time. Monitors and validates adherence to Policies and Procedures within the adjudication team, auditing as necessary to ensure productivity and performance to goals are accomplished or exceeded, including adjudication and claim accuracy, TTFF, and SLA of operational processes.
- Manages daily auditing reports and workflow to ensure claims are adjudicated accurately based on coordination of benefits, payor requirements, and eligibility, as well as rejection overrides requested in a timely manner.
- Reviews Gold Standard Initiative operational process and workflow queues to find opportunities to enhance adjudication team process and coordinate with Director of Pharmacy Operations to approve and roll out changes/updates.
- Implements and follows up on progress of any operational changes and updates to the adjudication process with the team and key stakeholders.
- Manages and maintains tools utilized by the adjudication team and offers frontline support to address system functionality questions and issues (Ex: provider eligibility portals, copay card portals, applications, etc.)
- Resolves escalations for difficult cases/questions to ensure accurate and timely completion of claim resolution. Provides thorough, accurate and timely responses to requests regarding claims information and ensures the same from the adjudication team.
- Works with Director of Pharmacy Operations on other responsibilities, projects, implementations, and initiatives as needed.
- Maintains a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws.
- Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.
- Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business
- Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.
Adjudication Manager Qualifications:
Education/Learning Experience
- Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Associates or Bachelor’s Degree or equivalent experience. Knowledge of insurance and applicable regulations
- Desired: Master’s degree equivalent experience, Certified Pharmacy Technician, Specialty pharmacy experience
Work Experience
- Required: 5 years pharmacy or pharmacy adjudication or equivalent experience, 1 years supervisor experience
- Desired: 7 years pharmacy or pharmacy adjudication or equivalent experience, 3 years in management role, Specialty pharmacy or related experience
Skills/Knowledge
- Required: NDC medication billing, PBM and medical contracts, healthcare audit experience, knowledge of Medicare, Medicaid, and commercial insurance, pharmacy test claim and NCPDP claim rejection resolution, coordination of benefits, excellent interpersonal skills, able to work with all levels of management and staff, vast knowledge of pharmacy terminology and process including sig codes, and roman numerals, brand/generic names of medication, advanced typing, math and analytical skills.
- Desired: Specialty pharmacy operations, leadership skills, independent decision-making abilities, able to conduct research, be resourceful, and self-reliant, excellent communication skills, drive to learn
Licenses/Certifications
- Required: Registration with Board of Pharmacy as required by state law
- Desired: Certified Pharmacy Technician (PTCB), Advanced Certified Pharmacy Technician with completion of Billing and Reimbursement certification
Behavior Competencies
- 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, leadership
Salary : $64,000
