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Claims Adjudicator Jobs (NOW HIRING)

Georgia

Adjudicator 1

Atlanta, GA

Professional experience working with disability, medical or insurance claims adjudication or ... investigation, health care, unemployment, workers compensation, social services, or related field.

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Claims Adjudicator information

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How much do claims adjudicator jobs pay per hour?

As of Aug 16, 2026, the average hourly pay for claims adjudicator in the United States is $26.74, according to ZipRecruiter salary data. Most workers in this role earn between $22.60 and $30.29 per hour, depending on experience, location, and employer.

What are some common challenges faced by claims adjudicators, and how can they be effectively managed?

Claims Adjudicators often encounter challenges such as managing a high volume of claims, interpreting complex policy details, and ensuring accuracy under tight deadlines. To effectively manage these, it's important to develop strong organizational skills, maintain up-to-date knowledge of insurance regulations, and use available adjudication software efficiently. Collaborating closely with other departments, such as customer service and medical review teams, also helps resolve ambiguous cases and ensures thorough, fair evaluations. Continuous training and open communication with supervisors can further support success in this role.

What is a claims adjudicator?

A claims adjudicator determines how much money will be paid after an insurance claim has been examined. Their duties include sorting through the research and interviews for each claim, and deciding the amount of cash settlement. A claims adjudicator examines many types of insurance policy claims, including medical, disability, and social security claims. This job requires knowledge of the insurance industry. Supervised on-the-job training is provided in entry-level roles. Additional qualifications for the career are strong analytical, communication, and organizational skills.

How much does a claims adjudicator make?

A claims adjudicator typically earns between $40,000 and $65,000 annually, depending on experience, location, and employer. Entry-level positions may start lower, while experienced professionals or those with specialized knowledge can earn higher salaries. The role often requires attention to detail and familiarity with claims processing systems.

What is the difference between Claims Adjudicator vs Claims Processor?

AspectClaims AdjudicatorClaims Processor
CredentialsHigh school diploma or equivalent; some roles may require insurance certificationsHigh school diploma or equivalent; minimal certifications often sufficient
Work EnvironmentOffice setting, insurance companies, healthcare organizationsOffice setting, insurance companies, healthcare organizations
Job FocusAnalyzing and evaluating insurance claims for accuracy and coverageProcessing claims, data entry, and basic claim handling
Common UsageInsurance industry, healthcare providersInsurance industry, healthcare providers

While both Claims Adjudicators and Claims Processors work within the insurance industry, Claims Adjudicators focus on evaluating and approving claims based on policy coverage, whereas Claims Processors handle the initial data entry and basic processing tasks. Understanding these differences helps job seekers identify roles that match their skills and career goals.

What are the key skills and qualifications needed to thrive as a claims adjudicator?

To excel as a Claims Adjudicator, you need strong analytical skills, attention to detail, and a solid understanding of insurance policies and regulations, often supported by relevant experience or a degree in business, finance, or a related field. Familiarity with claims management systems, insurance software, and sometimes certifications such as AIC (Associate in Claims) are commonly required. Excellent communication, problem-solving abilities, and integrity help you handle sensitive information and interact effectively with clients and colleagues. These skills ensure accurate, timely claim decisions and maintain trust with policyholders and insurers.

What does a claims adjudicator do?

A Claims Adjudicator is responsible for reviewing and processing insurance claims to determine whether they should be approved, denied, or adjusted. They examine documentation provided by claimants, healthcare providers, or other parties to ensure claims comply with policy terms and regulatory guidelines. Claims adjudicators may also communicate with claimants and providers to gather additional information, resolve discrepancies, and explain decisions. Their work helps ensure that claims are handled accurately and efficiently, protecting both the insurance company and the policyholder.
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Claims Adjudicator jobs near you
Infographic showing various Claims Adjudicator job openings in the United States as of August 2026, with employment types broken down into 92% Full Time, and 8% Contract. Highlights an 77% In-person, 8% Hybrid, and 15% Remote job distribution, with an average salary of $55,623 per year, or $26.7 per hour.

Pharmacy Claims Adjudication Specialist

Onco360

Woodridge, IL

$24/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Re-posted 18 days ago

Onco360 rating

7.7

Company rating: 7.7 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

19th of 112 rated pharmacies

Job description

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Woodridge, IL. This will be a Full-Time position. This position must be located within driving distance to our pharmacy, with a hybrid work style.
Shift times are between 8am and 8pm.
Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.
Starting salary from $24.00 an hour and up
Sign-On Bonus: $5,000 for employees starting before September 30th, 2026.
We offer a variety of benefits including:
  • Medical; Dental; Vision
  • 401k with a match
  • Paid Time Off and Paid Holidays
  • Tuition Reimbursement
  • Company paid benefits – life; and short and long-term disability
Pharmacy Adjudication Specialist Major Responsibilities:
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
Pharmacy Adjudication Specialists at Onco360...
  • Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.
  • Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information..
  • Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.
  • 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.
  • 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
  • Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)
  • Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.
  • 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.
  • 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.
  • Documents and submit requests for Patient Refunds when appropriate.
  • Maintain 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.
Pharmacy Adjudication Specialist Qualifications and Responsibilities...
  • Education/Learning Experience
    • Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication
    • Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience
  • Work Experience
    • Required: 2+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience
    • Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience
  • Skills/Knowledge
    • 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
    • Desired: Knowledge of Foundation Funding, Specialty pharmacy experience
  • Licenses/Certifications
    • Required: Registration with Board of Pharmacy as required by state law
    • Desired: Certified Pharmacy Technician (PTCB)
  • 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
#Company Values: Teamwork, Respect, Integrity, Passion

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