Executive Case Manager (Remote)

Key Responsibilities

• Relationship Management
  • Builds trusted relationships with patients, prescribers, and appropriate client stakeholders regarding reimbursement inquiries and challenges through proactive communication, timely and accurate execution of deliverables and demonstrated relentless passion for helping patients.
  • Manages all relationships in a manner that adheres to all relevant laws, regulations, program-specific operating procedures and industry standards related to access and affordability, including HIPAA and insurance guidelines.
• Inbound Call Management
  • Manages inbound calls as directed by the program-approved FAQs.
  • Triage patients to internal or external resources as appropriate.
• Personalized Case Management
  • Provides personalized case management to patients and HCPs including outbound communication to HCPs, specialty pharmacies and patients to communicate benefit coverage and/or appropriately help drive next steps in obtaining coverage and/or access to prescribed medicine.
  • All communications for case management will follow the guidelines set forth for the program and only provide information publicly available and/or outlined in the patient insert.
  • Leverages electronic tools to identify benefits and payer coverage; completes manual benefit investigation as needed.
  • Identifies and communicates patient’s plan benefit coverage including the need for prior authorization, appeal, tier exception, and/or formulary exclusions.
• Other Tasks
  • Serves as a subject matter expert to internal team as required and appropriate.
  • Uses electronic resources to obtain benefit coverage outcome and if needed, outbound call to payers and HCPs to follow up on proper submission and/or outcome.
  • Captures nurse teach with nurse educators, as applicable to program.
  • Supports adherence services as applicable to program.
  • Identifies peer support resources for patients.
  • Proactively communicates needs for reverification of prior authorization or re-enrollment.
  • Identifies and reports adverse events, product complaints, special situation reports and/or medical inquiries received in accordance with program operating procedures and the Business Rules.
  • Documents all activities within the Lynk system, maintaining detailed records of reimbursement activities, including claims status, payments, and appeals.
  • Generates reports and analysis as needed to identify trends and opportunities for improvement in accordance with business requirements.

Qualifications

• Completion of Bachelor's degree (or higher) required.
• A degree in healthcare administration, social science or similar related fields is strongly preferred.
• Minimum two years of experience in healthcare access delivery or management is strongly preferred.
• Five or more consecutive years of experience in relevant field will be considered in lieu of degree.
• Certification examples include PACS (Prior Authorization Certified Specialist), CHES (Certified Health Education Specialist) or CCM in healthcare or social science (Certified Case Manager).
• Strong understanding of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance processes.
• Demonstrated examples of executing within guardrails recognizing urgency and consistently delivering patient centric results.
• Excellent attention to detail and organizational skills.
• Ability to prioritize tasks and work efficiently in a fast-paced environment.
• Effective written and verbal communication and interpersonal skills, with the ability to interact professionally with diverse stakeholders.
• Demonstrates the ability to think critically and issue resolution.
• Knowledge of healthcare compliance regulations, including HIPAA and Medicare/Medicaid guidelines.

Physical Demands & Work Environment

• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee is frequently required to sit for long periods of time, use hands to type, handle or feel; and reach with hands and arms.
• Prefer candidates who can type at least 35 words per minute with 97% accuracy.
• Although very minimal, flexibility to travel as needed is preferred.
• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, etc.

Benefits

• Medical, dental, and vision plans, including HSA- and FSA-eligible options, with Valeris contributing toward premium costs.
• Additional health support, including telehealth and Employee Assistance Program (EAP) services.
• Company match on Health Savings Account contributions.
• Free Basic Life and AD&D coverage equal to your annual earnings, with a minimum of $50,000 and a maximum of $300,000.
• Company-paid Short-Term Disability coverage, with the option to purchase Long-Term Disability.
• 401(k) Retirement Savings Plan with 100% match on the first 5% you contribute, with immediate vesting.
• Paid Time Off (PTO) and Sick Leave to support work-life balance.
• Opportunities for advancement in a company that supports personal and professional growth.
• A challenging, stimulating work environment that encourages new ideas.
• A mission-driven, inclusive culture where your work makes a meaningful impact.