Patient Care Advocate

This is a fully remote position, open to applicants in Oregon, +1 more state.

📋 Description

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

• Assist patients and providers in navigating the prior authorization and appeals processes for prescription medications.

• Evaluate eligibility for copay and financial assistance, connecting patients with appropriate third-party resources.

• Interpret regulations, policies, and advancements within the Pharmacy Benefit Manager (PBM) sector.

• Analyze intricate benefit, coverage, and authorization inquiries, providing resolution guidance.

• Manage cases from start to finish, addressing issues and escalating when necessary.

• Advise members and patients on coverage options, benefits, and financial assistance resources.

• Collaborate with members, providers, pharmacies, and community resources to eliminate barriers to care.

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

• Conduct benefit verifications and test claims for accuracy.

• Ensure precise case documentation and rationale for decisions made.

• Assess quality, identify trends, and suggest improvements to processes.

⛳️ Requirements

• Must be a resident of Washington or Oregon.

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

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

• In-depth understanding 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.

• Strong analytical and problem-solving capabilities, including the interpretation of claims and benefit information and the navigation of complex healthcare and payer systems.

• Patient-centered mindset and empathy in challenging or high-stakes scenarios.

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

• Excellent organizational skills and a keen attention to detail; able to manage multiple priorities and adapt to evolving demands.

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

• Dedication to patient confidentiality and adherence to ethical and regulatory standards.

• A private, quiet workspace suitable for remote work.

🏝️ Benefits

• Competitive salary, including health, dental, vision, and additional benefits.

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

• An environment where individuals flourish and the business prospers.

• Flexible remote work arrangements.