Senior Case Manager, Reimbursement

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

📋 Description

• Oversee and coordinate daily caseload activities to ensure timely completion of all case elements and tasks, facilitating the progression of cases through the required processes.

• Serve as the primary contact for prior authorization and appeal processing communications with patients, healthcare providers, field reimbursement representatives, and other external stakeholders.

• Act as an advocate for patients, guiding them through the reimbursement process while coordinating additional patient access services within program guidelines.

• Conduct quality checks on cases and report trends to leadership.

• Ensure adherence to quality and production standards through effective housekeeping techniques while complying with relevant company, state, and federal safety and environmental policies.

• Troubleshoot complex cases involving multiple disease states, collaborating with key stakeholders (both internal and external) to ensure an optimal initiation of therapy.

• Report adverse drug events experienced by patients in alignment with pharmaceutical regulations.

• Identify product quality complaints and relay caller or written information to the manufacturer.

• Serve as a resource for case managers by assisting with prior authorization and appeal requirements, providing guidance, answering process-related questions, and addressing escalated issues as needed.

• Offer support for at-risk patients and prescribers to prevent interruptions in the initiation or continuation of therapy.

• Collaborate monthly with senior case managers, management, and the quality team to assess quality trends and develop process improvement initiatives for the upcoming month.

• Prepare and deliver team huddles and client presentations as appropriate (at least one presentation each month).

• Perform additional duties as assigned.

⛳️ Requirements

• Bachelor’s degree or six years of relevant professional experience.

• Preferred: Five (5) or more years of relevant experience in pharmacy benefit management, specialty pharmacy, or patient support/access (HUB) services.

• Required: Three (3) or more years of relevant experience in pharmacy and/or medical benefit verifications, prior authorizations, and/or appeals.

• Preferred: Experience as a Medical Assistant, Social Worker, or Senior Reimbursement Specialist.

• Proficiency in Microsoft Office applications.

• Familiarity with medical and claims processing terminology.

• Exceptional written and verbal communication skills, including the ability to provide clear instructions.

• Strong critical thinking skills and the ability to manage multiple tasks simultaneously.

🏝️ Benefits

• Remote work opportunities.

• Competitive salary packages.

• Opportunities for career advancement.

• 401K plan with company matching.

• Tuition reimbursement programs.

• Flexible working environment.

• 20 days of PTO (Paid Time Off).

• Paid holidays.

• Employee assistance programs.

• Medical, dental, and vision insurance coverage.

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

• Telemedicine services (virtual doctor appointments).

• Wellness programs.

• Adoption assistance.

• Short-term disability coverage.

• Long-term disability coverage.

• Life insurance benefits.

• Discount programs.