Patient Care Advocate

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

📋 Description

• Act as a subject matter expert regarding pharmacy and medical benefit frameworks for Medicare, Medicaid, and commercial payers.

• Analyze coverage and address intricate benefit inquiries.

• Offer guidance on prior authorization and appeals processes for prescription drugs.

• Evaluate eligibility for copay and financial support, connecting patients with third-party aid.

• Interpret regulations, policies, and advancements in the PBM industry.

• Address benefit, coverage, and authorization inquiries and formulate resolution strategies.

• Manage cases comprehensively, resolving issues and escalating when necessary.

• Advise members and patients regarding coverage, benefits, and financial support options.

• Collaborate with members, providers, pharmacies, and other stakeholders to eliminate barriers to care.

• Review claims against benefit guidelines and determine necessary corrective actions.

• Perform benefit verification and test claims.

• Ensure accurate case documentation and rationales for decisions.

• Assess quality, identify trends, and suggest process enhancements.

⛳️ Requirements

• Must reside in Minnesota and be open to traveling within the state.

• Bachelor's degree in a healthcare-related field (preferred) or equivalent experience.

• Over 4 years of demonstrated experience in pharmacy benefits, managed care, or patient advocacy within a healthcare or PBM environment, including roles necessitating independent judgment and decision-making.

• In-depth knowledge of pharmacy and medical benefit structures, prior authorization and appeals, healthcare regulations, and payer/insurance processes.

• Exceptional communication and interpersonal abilities, capable of translating complex benefit and coverage details into clear guidance for members and providers.

• Strong analytical and problem-solving capabilities, with the ability to interpret claims and benefit information while navigating intricate healthcare and payer systems.

• A patient-centered mindset, demonstrating empathy to assist members in challenging or high-pressure situations.

• Proficiency in claims, benefit verification, and case management systems, along with strong general computer skills.

• Excellent organizational abilities and attention to detail, with the capacity to handle multiple priorities and adapt to shifting demands.

• Capability to work both independently and collaboratively with internal and external stakeholders.

• Commitment to maintaining patient confidentiality and complying with ethical and regulatory standards.

• A private, quiet workspace for remote work.

🏝️ Benefits

• Competitive compensation, including health, dental, vision, and other benefits.

• Opportunity to influence industry change in the pharmacy benefits management sector while achieving high-quality patient outcomes.

• A culture where individuals thrive and the business prospers.

• Remote work arrangement.