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Medical Adjudication Jobs (NOW HIRING)

Protection Strategies Inc

Adjudicator

Washington, DC · On-site

$90K - $100K/yr

Medical, Dental, Vision, Telemedicine * Financial Support: 401(K) Retirement Plan, Tuition ... OSSI will only provide the contractor training on OSSI adjudication processes. * Proficient in ...

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Medical Adjudication information

See salary details

$36.5K

$164.7K

$337K

How much do medical adjudication jobs pay per year?

As of Jun 23, 2026, the average yearly pay for medical adjudication in the United States is $164,731.00, according to ZipRecruiter salary data. Most workers in this role earn between $64,000.00 and $268,500.00 per year, depending on experience, location, and employer.

What does medical mean?

In the context of medical adjudication, 'medical' refers to matters related to health, healthcare services, and clinical assessments. Medical professionals review patient records, diagnoses, and treatment plans to determine insurance claims or benefits eligibility. Strong knowledge of medical terminology and documentation is essential for this role.

Does medical aid cover hair transplants?

Medical adjudicators evaluate insurance claims for procedures like hair transplants, but coverage depends on the specific medical aid plan and whether the procedure is deemed medically necessary. Generally, cosmetic hair transplants are not covered unless they are part of reconstructive surgery following injury or medical conditions. It is advisable to review the policy details or consult with the insurance provider for coverage specifics.

Is Medi-Cal the same as Medicaid?

Medical Adjudication professionals should know that Medi-Cal and Medicaid are related but not identical; Medi-Cal is California's Medicaid program, while Medicaid is a federal and state partnership providing health coverage across the U.S. Each state administers its own Medicaid program, which may have different names and coverage options. Understanding these differences is important when processing claims or verifying coverage for clients.

What's the maximum income to qualify for Medi-Cal?

For Medical Adjudication roles, eligibility for Medi-Cal generally depends on income levels relative to the Federal Poverty Level (FPL). As of 2023, most adults qualify if their income is at or below 138% of the FPL, which varies by household size. Specific income limits are updated annually and can differ based on the applicant's circumstances and program categories.

What is the difference between Medical Adjudication vs Medical Coding?

AspectMedical AdjudicationMedical Coding
Primary RoleReviewing and deciding insurance claim outcomes based on policy and medical documentationAssigning standardized codes to medical diagnoses and procedures for billing and record-keeping
Required CertificationsOften requires claims processing or adjudication certifications, knowledge of insurance policiesCertified Professional Coder (CPC), Certified Coding Specialist (CCS)
Work EnvironmentInsurance companies, healthcare providers, third-party payersHospitals, clinics, billing companies, insurance companies

Medical Adjudication involves evaluating insurance claims to determine coverage and payment, while Medical Coding focuses on translating medical services into codes for billing. Both roles require understanding healthcare documentation, but they serve different functions in the claims process.

More about Medical Adjudication jobs
What cities are hiring for Medical Adjudication jobs? Cities with the most Medical Adjudication job openings:
What states have the most Medical Adjudication jobs? States with the most job openings for Medical Adjudication jobs include:
What job categories do people searching Medical Adjudication jobs look for? The top searched job categories for Medical Adjudication jobs are:
Medical Adjudication jobs near you
Infographic showing various Medical Adjudication job openings in the United States as of June 2026, with employment types broken down into 2% As Needed, 82% Full Time, and 16% Part Time. Highlights an 81% Physical, 3% Hybrid, and 16% Remote job distribution, with an average salary of $164,731 per year, or $79.2 per hour.
Pharmacy Claims Adjudication Specialist

Pharmacy Claims Adjudication Specialist

Onco360

Waltham, MA

$26/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 25 days ago

Job description

We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in Waltham, MA. 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 currently available: 10:00am-6:30 pm EST
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 $26.00 an hour and up
Sign-On Bonus: $5,000 for employees starting before July 31, 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.
  • Documenst 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

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