Case Manager, Reimbursement

Brief Description

The primary purpose of this position is to provide day-to-day case management oversight and coordination of assigned caseload to ensure parties responsible for tasks are completing them timely, as well as act as a primary resource for patients, healthcare providers and field reimbursement.

The Case Manager is responsible for ensuring prior authorizations, reauthorizations and appeals are obtained in a timely manner, as well as ensuring accurate documentation of payer information and patient status.

In addition, the Case Manager is responsible for completing a pre-screen to determine eligibility for additional services such as injection services, co-pay mitigation, and patient assistance programs (PAP), if applicable.

Specific Job Duties

• Provide day-to-day oversight and coordination of caseload to ensure all case elements and tasks are completed timely and ensure cases move through the process as required.
• Act as single point of contact responsible for prior authorization and appeal processing communications to patients, healthcare providers, field reimbursement representatives and other external stakeholders.
• Communicate patient benefits and responsibility timely and accurately.
• Assess and refer patients appropriately for special programs/services when appropriate.
• Perform quality checks on cases and report trends to leadership.
• Responsible for good housekeeping techniques, adhering to quality and production standards while complying with all applicable company, state and federal safety and environmental programs and procedures.
• Troubleshoot complex cases, spanning multiple disease-states, while interfacing with key stakeholders (internal/external) to ensure optimal start to therapy.
• Report Adverse Drug Events that have been experienced by the patient in accordance pharmaceutical requirements.
• Navigate and refer patients to appropriate resources for product quality complaints.

Desired Skills And Qualifications

• Bachelor’s degree or six years of relevant working experience
• Two (2) or more years of relevant experience in pharmacy benefit management preferred
• Medical Assistant, Social Worker or Senior Reimbursement Specialist experience preferred
• Certification preferred but not required
• Proficient in Microsoft Office applications
• Knowledge of medical and claims processing terminology
• Excellent written/verbal communication to include providing clear instructions
• Must possess a strong critical thinking skillset along with the ability to multi-task