Reimbursement Case Manager

Purpose:

The Reimbursement Case Manager is a professional client facing role responsible for various functions,functions related to supporting patients, healthcare providers, and business partners with circumstances related to pharmacy reimbursements,includingaccurateandtimelyresponse to client inquiriesregardingspecific referral status or escalation. The Reimbursement Case Manager serves as a primary point of contact for professional, concise internal and external communicationregardingcase status updates, next steps in prescription processing, communication of reimbursement issues,etc. The Reimbursement Case Managers will interact directly with external clients such as manufacturers as well as internal teams including Operations and Program Management.The Reimbursement Case Manager will report tothe Clinical Pharmacist and Implementation Manager.

Responsibilities:

• Serve as primarypoint of contact and case manager for client and customer inquiries and escalations
• Process benefits investigations, benefits verifications, prior authorization submissions, and appeals as necessary to accelerate patient care access
• Coordinates services with internal program operations and Program Management
• Ability tocoordinateand collaborate with manufacturer representatives, HCP offices and other key personnel on complex cases which require prior authorization or appeals support
• Manage patient claims for prescription drug and medical benefits in relation to providing excellent specialty pharmacycare
• Establishself as regional expert on payer trends, product access, and reporting reimbursement trends and/or delays (i.e.denials, underpayment, access delays, etc.)
• Work independently to complete assigned workin accordance withStandard Operating Procedures and defined service levels to complete program enrollment, answer inquiries, and coordinate access totherapies
• Process of patient and prescriber requestsin order toensure access to therapyin a timelymanner
• Use high-level problem-solving skills to research cases independently, using professional judgement to make sounddecisions
• Maintain frequent phone contact with internal operational staff, external client, and external specialtypharmacies
• Provide exceptional, white glove, customer service to internal and external customers; resolves any customer and client requests ina timelyandaccuratemanner; escalatesappropriately

• Provide support to ensure efficient referral processing from referral intake to triaging ofprescription
• Independently and effectively resolve complex issuesrelated to pharmacy reimbursement and patient support withcreativity andinnovation
• Strong compliance mindset,demonstratingclear understanding of patient privacylaws
• Active participation in building andmaintainingrespectful, collaborative internal/external team relationships,exercisingand encouraging positivity.

Required Qualifications:

• High school diploma or equivalent
• 2+ years of relevant pharmacy reimbursement/insurance experience, includingbenefit investigation and benefit verification of prescription benefits
• 2+ years of relevant pharmacy case management experience
• 1+years experienceas a pharmacy technician
• 1+years experienceoperatinginCareTendPharmacy Management System
• Working knowledge of BI/BV process, pharmacy and prescription benefits, prior authorization process, and pharmacy access support solutions
• Ability to communicate in a clear, logical, effective, and consistent manner
• Ability to independently manage case load, prioritize work, and use time management skills to manage deliverables
• Empathy, drive, and commitment to exceptional service

Preferred Qualifications:

• Associate’s Degree or Bachelor’sDegree
• Understanding of plan types – Government, Commercial, Medicaid, VA, Fed
• Possess a strong understanding of biologic/specialty pharma market and patient access challenges

• Knowledge of insurance structure (ex PBM’s, major medical plans, co-pay assistance /cards)
• Working Knowledge of Third-Party and other Foundation programs
• Basic understanding of Co-Pay Assistance (if applicable)