Sr. 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.

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.
• Serve as a patient advocate and resource for patients as they navigate through the reimbursement process while coordinating any additional patient access services within program guidelines.
• 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.
• Recognize a product quality complaint and forward caller/written information to a manufacturer.
• Act as point of contact for case managers to assist with prior authorization and appeal requirements, provide guidance, answer process questions and address escalated issues when appropriate.
• Provides support for at-risk patients and prescribers to help mitigate any lapse in the start or continuation of therapy.
• Collaborate with other senior case managers, managers and quality team on a monthly basis to review quality trends, creating process improvement initiatives for the next month.
• Prepares and presents team huddles, and client presentations as deemed appropriate (minimum one presentation per month).

Desired Skills And Qualifications

• Bachelor’s degree or six years of relevant working experience
• Five (5) or more years of relevant experience in pharmacy benefit management, specialty pharmacy or patient support/access (HUB) services preferred
• Three (3) or more years of relevant experience in pharmacy and/or medical benefit verifications, prior authorization and/or appeals required
• Medical Assistant, Social Worker or Senior Reimbursement Specialist experience preferred
• 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

Benefits

• Remote opportunities
• Competitive salaries
• Growth opportunities for promotion
• 401K with company match
• Tuition reimbursement
• Flexible work environment
• 20 Days PTO (Paid Time Off)
• Paid Holidays
• Employee assistance programs
• Medical, Dental, and vision coverage
• HSA/FSA
• Telemedicine (Virtual doctor appointments)
• Wellness program
• Adoption assistance
• Short term disability
• Long term disability
• Life insurance
• Discount programs