Pharmacy Patient Care Case Manager

Job Description

Job Description

 

Who We Are:

OptiMed Health Partners optimizes health outcomes and quality of life through personalized and coordinated care. We have been serving patients for over 30 years with a focus on high-quality care in retail pharmacy, specialty pharmacy, and infusion services. The OptiMed Vision reimagines healthcare solutions to achieve unsurpassed value. Our results-oriented culture fosters learning, providing growth opportunities for our employees and exceptional care for our patients in all 50 states.

The Impact of this Role:

The Pharmacy Patient Care Case Manager serves as the primary liaison between patients, healthcare providers, infusion service providers, specialty pharmacies, and health plan stakeholders to facilitate appropriate, cost-effective, and clinically suitable infusion care. This role is responsible for coordinating patient placement across home infusion, ambulatory infusion centers, physician office infusion suites, and health system outpatient infusion centers while ensuring continuity of care, reimbursement alignment, and positive patient outcomes.
The position requires strong negotiation, contracting, and relationship management skills to secure mutually acceptable reimbursement arrangements with providers and infusion organizations. The Case Manager will also review and interpret contractual language, service agreements, letters of agreement (LOAs), and reimbursement terms to ensure compliance with organizational policies and financial objectives. .

What You’ll be Doing:

Patient Site-of-Care Coordination
• Assess patient-specific clinical, financial, geographic, and benefit plan factors to determine the most appropriate infusion site of care.
• Coordinate transitions of care between hospital outpatient departments, home infusion providers, ambulatory infusion centers, physician offices, and integrated delivery networks.
• Collaborate with patients, caregivers, physicians, pharmacists, nurses, and infusion providers to ensure timely initiation and continuation of therapy.
• Monitor patient case progression and proactively resolve barriers to treatment access.
• Ensure continuity of care throughout site transitions, therapy changes, and provider referrals.

Provider Relations & Contract Negotiation

• Negotiate reimbursement rates, service agreements, and provider contracts with infusion providers, health systems, ambulatory infusion centers, and home infusion organizations, reviewing terms and legal language for accuracy and compliance.
• Own end to end facilitation and negotiation of single-case agreements and letters of agreement when network participation is unavailable or insufficient.
• Develop and maintain productive relationships with provider organizations and key stakeholders, balancing patient access needs, provider expectations, and organizational cost-management objectives.
Identify financial, operational, and contractual risks associated with provider arrangements.
• Collaborate with legal, contracting, network management, and finance teams to finalize agreements.
• Escalate complex negotiations and reimbursement issues as necessary.

Case Management & Documentation

• Maintain accurate case records, provider communications, and documentation of negotiation outcomes, reimbursement agreements, and patient placement decisions, ensuring compliance with company policies, payer requirements, and applicable regulations.
• Track key performance indicators including treatment initiation timelines, savings opportunities, network utilization, and patient satisfaction.
• Participate in quality improvement initiatives and process optimization effort 

Who You’ll be Working With:

In this role, you would work closely with a wide range of internal and external healthcare partners. Most frequently, you would collaborate with patients and their caregivers, as well as physicians, pharmacists, nurses, and infusion service providers to coordinate care and ensure timely treatment. 

You would also partner with specialty pharmacies, home infusion organizations, infusion centers, and health system stakeholders to determine appropriate sites of care. Internally, you would engage with teams such as finance, contracting, and network management to negotiate agreements and support reimbursement strategies. 

Skills and Experience You’ll Bring to the Table:

• Bachelor’s degree in Healthcare Administration, Business, Nursing, Pharmacy, or related field preferred
• 3–5+ years of experience in healthcare case management, specialty pharmacy, infusion services, provider relations, managed care, or healthcare contracting required
• Experience coordinating infusion therapies and alternative sites of care preferred
• Experience reviewing contracts, agreements, or reimbursement arrangements required
• Strong knowledge of healthcare reimbursement methodologies and payer operations required
• CNA, LPN, RN, or other clinical credential preferred
• Certification in Case Management (CCM) or related credential preferred

Competencies You’ll Bring to the Table:

• Patient Advocacy
• Financial Analysis
• Relationship Management
• Clinical Care Coordination
• Problem Resolution
• Provider Negotiation
• Conflict Resolution
• Cross-Functional Collaboration and Communication

Work Environment:

This is a full-time, with occasional on-site collaboration at OptiMed’s headquarters in Kalamazoo, Michigan. The role operates in a fast-paced environment where multiple projects and integrations are managed simultaneously.

The position requires prolonged computer use and the ability to work across multiple systems and tools daily. Occasional on-site presence may be required for collaboration, system setup, or project needs.

OptiMed Health Partners provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.