Clinical Case Manager, RN

This is a fully remote position, open to applicants in United States.

📋 Description

• Acts as a Clinical Case Manager, providing telephonic support to healthcare providers and patients for client-funded contracts.

• Responsibilities include telephonic assistance to healthcare providers, reviewing payor-specific coverage criteria, conducting clinical reviews of prior authorizations and appeals, and delivering written communication using client-approved program resources.

• This position will foster and cultivate strong customer relationships while supporting all efforts that promote patient access.

• Comply with principles outlined in program-specific contractual agreements and company policies.

• Exhibit clinical proficiency in reimbursement, product knowledge, and medical records, and will oversee training for other team members on these topics.

• Address complex cases, recognize trends across various disease states, analyze data, and resolve escalated issues related to intricate reimbursement from both internal and external stakeholders, including prior authorization denials and appeals.

• Review payer product coverage criteria and denial letters to ensure proper documentation is submitted for coverage determinations.

• Maintain consistent and effective communication with healthcare providers, utilizing approved resources, regarding payer coverage criteria and any missing information needed for submissions.

• Serve as a professional resource for IB/OB inquiries, focusing on data collection, providing accurate and timely updates, and documenting summaries of follow-up phone calls, patient inquiries, and outcomes including clinical notes and medical record/chart reviews when necessary.

• Collect, analyze, and prepare data for Quarterly Business Reviews (QBRs) and/or client meetings.

• Participate in program-specific customer meetings and training sessions.

• Report Adverse Drug Events experienced by patients as per manufacturer requirements.

• Attend manufacturer-hosted conferences, customer meetings/training, and QBRs as requested, including potential travel for in-person attendance.

• Undertake special projects and other duties as assigned.

⛳️ Requirements

• Minimum requirement of an associate degree and a professional nursing license.

• Must hold a Registered Nurse License in good standing in the state of employment; telephonic clinical roles require a Compact State License in eligible states; additionally, the employee must be willing to obtain a Compact State license as their state adopts Compact legislation.

• Telephonic clinical roles necessitate a California State License, and the employee should be prepared to obtain additional Single State Licenses upon request.

• Prior experience in the PBM and/or healthcare sector is essential.

• Demonstrated ability to research, analyze, prepare reports, and document information clearly.

• A minimum of 2 years' experience in a customer service environment showcasing advanced issue resolution skills, preferably in a call center setting.

• Proficient in Microsoft Office applications, particularly Excel.

• Capability to thrive in a fast-paced environment and manage multiple tasks simultaneously.

• Exceptional written and verbal communication skills.

• Strong problem-solving and troubleshooting abilities, including critical thinking skills.

• Excellent attention to detail, relationship-building abilities, and the capacity to train other team members.

🏝️ Benefits

• Opportunities for remote work.

• Competitive salary packages.

• Opportunities for career advancement.

• 401K plan with company matching.*

• Tuition reimbursement available after 90 days of employment.

• Flexible work environment.

• 20 days of paid time off (PTO).

• Paid holidays.

• Employee assistance programs.

• Comprehensive medical, dental, and vision coverage.

• Health Savings Account (HSA) and Flexible Spending Account (FSA) options.

• Access to telemedicine services (virtual doctor appointments).

• Wellness programs available.

• Adoption assistance provided.

• Short-term disability coverage after 90 days of employment.

• Long-term disability coverage.

• Life insurance options.

• Discount programs available.