Executive Case Manager (Remote)

About the role

The Executive Case Manager role at Valeris is a remote position available to candidates residing in North Carolina. This role involves managing patient journeys from initiation to closure, providing personalized case management, and handling various aspects of insurance coverage and access challenges.

Responsibilities

• Builds trusted relationships with patients, prescribers, and stakeholders regarding reimbursement inquiries and challenges through proactive communication, timely and accurate execution of deliverables, and demonstrating a relentless passion for helping patients.
• Manages all relationships in compliance with relevant laws, regulations, program-specific operating procedures, and industry standards related to access and affordability, including HIPAA and insurance guidelines.
• Supports inbound and outbound calls to patients, caregivers, specialty pharmacies, and healthcare professionals, performing post-Benefit Investigation calls to explain coverage options and next steps in the access journey.
• Manages client inquiries as appropriate, such as case-specific statuses, and manages HCP inquiries according to business rules.
• Leverages electronic tools to identify benefits and payer coverage; completes manual benefit investigations as needed, identifies and communicates patient’s plan benefit coverage, including the need for prior authorization, appeal, tier exceptions, and/or formulary exclusions.
• Serves as a subject matter expert to internal team as required and appropriate, utilizes electronic resources to obtain benefit coverage outcomes, and follows guidelines for case management.
• Identifies peer support resources for patients, proactively communicates needs for re-verifications of prior authorizations or re-enrollment, and identifies and reports adverse events, product complaints, special situation reports, and/or medical inquiries received in accordance with program operating procedures and business rules.
• Documents all activities within the PharmaCord Lynk system, maintains detailed records of reimbursement activities, including claims status, payments, and appeals, and generates reports and analyses as needed to identify trends and opportunities for improvement.
• Utilizes Valeris’ values as the driving force behind the team’s success, adheres to training deadlines for all corporate policies and procedures, and ensures all SOPs are followed with consistency.
• Performs additional tasks or projects as assigned.

Qualifications

• Completion of a Bachelor's degree (or higher) required, with a degree in healthcare administration, social science, or similar related fields preferred.
• Minimum two years of experience in healthcare access delivery or management strongly preferred, or five or more consecutive years of experience in relevant fields in lieu of degree.
• 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.

Benefits

Valeris offers a comprehensive benefits package including medical, dental, and vision plans, with HSA- and FSA-eligible options, and a company match on Health Savings Account contributions. Additional health support includes telehealth and Employee Assistance Program (EAP) services. The company also provides Short-Term Disability coverage, with the option to purchase Long-Term Disability. Employees can participate in a 401(k) Retirement Savings Plan with a 100% match on the first 5% contributed, with immediate vesting. Paid Time Off (PTO) and Sick Leave are provided to support work-life balance. Valeris offers nine paid holidays plus two floating holidays, opportunities for advancement, and a challenging, stimulating work environment that encourages new ideas.

Pay

Details on pay are not specified in the job posting.

Schedule

Details on schedule are not specified in the job posting.

Skills

Key skills required for this role include a strong understanding of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance processes, along with excellent communication and interpersonal skills.