Sr. Reimbursement Case Manager

About the role

Under the general supervision of the Supervisor and Director, the Senior Reimbursement Case Manager is responsible for customer service and case management. The role involves working interactively with patients, healthcare providers, specialty pharmacies, and manufacturer clients to support various reimbursement functions, including benefits investigations, prior authorization support, and call triage.

This position serves as a single point of contact for providers, patients, and product/sales teams, handling escalated accounts and issues while managing special projects and tasks. The Senior Reimbursement Case Manager acts as a patient advocate, enhancing collaborative relationships between payers, healthcare providers, and patients to coordinate access to therapies and support services.

Responsibilities

• Act as a single point of contact and voice for all providers, patients, and product/sales teams.
• Handle escalated accounts and issues.
• Manage special projects and tasks.
• Serve as a patient advocate and enhance collaborative relationships between payers, healthcare providers (HCP), and patients.
• Coordinate access to therapies, conduct appropriate follow-up, and facilitate access to support services.
• Manage a regional caseload.
• Collect and review patient insurance benefit information as authorized by program SOPs.
• Assist physician office staff and patients in completing and submitting insurance forms and program applications in a timely manner.
• Track and follow up on prior authorization and appeal requests.
• Provide exceptional customer service to internal and external customers; resolve requests in a timely and accurate manner.
• Maintain frequent phone contact with provider representatives, third-party customer service representatives, and pharmacy staff.
• Report reimbursement trends or delays to the supervisor.
• Process correspondence and provide documentation required for prior authorization requests, including demographic details, authorizations, NPI numbers, and referring physicians.
• Coordinate with inter-departmental associates as necessary.
• Communicate effectively with payors to ensure accurate and timely benefit investigations.
• Work on problems of moderate scope, analyzing data and exercising judgment within defined standard operating procedures.
• Maintain knowledge of HIPAA regulations and ensure compliance at all times.
• Maintain regular and reliable attendance, including being present, on time, and prepared for work as scheduled.
• Perform other related duties as assigned.

Requirements

• Previous 3+ years of experience in a physician’s office, healthcare setting, and/or insurance background preferred.
• Bachelor’s Degree preferred.
• Excellent verbal and written communication skills.
• Ability to multi-task and adapt to changing priorities.
• Proficient keyboard skills and competency in MS Word and Excel.
• Knowledge of HIPAA regulations.
• Detailed oriented and highly organized.
• Excellent interpersonal skills.
• Knowledge of pharmacy benefits and medical benefits.
• Global understanding of commercial and government payers preferred.
• Ability and initiative to work independently or as a team member.
• Problem-solving skills.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to sit.
• The employee must occasionally lift and/or move up to 10 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Schedule

• Must be flexible on schedule and hours.
• Extensive travel is required (60% travel).