Reimbursement Case Manager

Job Description

Job Description

Purpose: 

The Reimbursement Case Manager is a professional client facing role responsible for various functions, functions related to supporting patients, healthcare providers, and business partners with circumstances related to pharmacy reimbursements, including accurate and timely response to client inquiries regarding specific referral status or escalation. The Reimbursement Case Manager serves as a primary point of contact for professional, concise internal and external communication regarding case status updates, next steps in prescription processing, communication of reimbursement issues, etc. The Reimbursement Case Managers will interact directly with external clients such as manufacturers as well as internal teams including Operations and Program Management. The Reimbursement Case Manager will report to the Clinical Pharmacist and Implementation Manager.

Responsibilities:  

• Serve as primary point of contact and case manager for client and customer inquiries and escalations
• Process benefits investigations, benefits verifications, prior authorization submissions, and appeals as necessary to accelerate patient care access
• Coordinates services with internal program operations and Program Management
• Ability to coordinate and collaborate with manufacturer representatives, HCP offices and other key personnel on complex cases which require prior authorization or appeals support
• Manage patient claims for prescription drug and medical benefits in relation to providing excellent specialty pharmacy care
• Establish self as regional expert on payer trends, product access, and reporting reimbursement trends and/or delays (i.e. denials, underpayment, access delays, etc.)
• Work independently to complete assigned work in accordance with Standard Operating Procedures and defined service levels to complete program enrollment, answer inquiries, and coordinate access to therapies
• Process of patient and prescriber requests in order to ensure access to therapy in a timely manner
• Use high-level problem-solving skills to research cases independently, using professional judgement to make sound decisions
• Maintain frequent phone contact with internal operational staff, external client, and external specialty pharmacies
• Provide exceptional, white glove, customer service to internal and external customers; resolves any customer and client requests in a timely and accurate manner; escalates appropriately

• Provide support to ensure efficient referral processing from referral intake to triaging of prescription
• Independently and effectively resolve complex issues related to pharmacy reimbursement and patient support with creativity and innovation
• Strong compliance mindset, demonstrating clear understanding of patient privacy laws
• Active participation in building and maintaining respectful, collaborative internal/external team relationships, exercising and encouraging positivity.

Required Qualifications: 

• High school diploma or equivalent
• 2+ years of relevant pharmacy reimbursement/insurance experience, including benefit investigation and benefit verification of prescription benefits
• 2+ years of relevant pharmacy case management experience
• 1+ years experience as a pharmacy technician
• 1+ years experience operating in CareTend Pharmacy Management System
• Working knowledge of BI/BV process, pharmacy and prescription benefits, prior authorization process, and pharmacy access support solutions
• Ability to communicate in a clear, logical, effective, and consistent manner
• Ability to independently manage case load, prioritize work, and use time management skills to manage deliverables
• Empathy, drive, and commitment to exceptional service

Preferred Qualifications: 

• Associate’s Degree or Bachelor’s Degree
• Understanding of plan types – Government, Commercial, Medicaid, VA, Fed
• Possess a strong understanding of biologic/specialty pharma market and patient access challenges

• Knowledge of insurance structure (ex PBM’s, major medical plans, co-pay assistance /cards)
• Working Knowledge of Third-Party and other Foundation programs
• Basic understanding of Co-Pay Assistance (if applicable)
• Strong analytical and organizational skills with attention to detail
• Excellent verbal and written communication skills
• Ability to proficiently use Microsoft Excel, Outlook and Word
• Knowledge of Rare Diseases
• Experience documenting requirements, creating training materials and working directly with end users
• Self-starter with ability to exercise sound independent judgment

Work Environment
This job operates in a professional office environment and teleworking from the employee’s home address listed in their employment file. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. When telecommuting employees must have reliable internet access in order to access required systems and software associated with the position's responsibilities. The amount of time the employee is expected to work per day or pay period will not change as a result of participation in the teleworking program. Employees are responsible for the set-up of their home office environment, including physical set-up, internet connection, phone line, electricity, good lighting, comfortable temperature, furniture, etc. Employee’s teleworking space should be separate and distinct from their “home space” and allow for privacy. Vanscoy Rare Pharmacy expects employees teleworking to be as efficient and professional as if they were in the office. The amount of time spent in office or teleworking is contingent upon the needs/priorities of Vanscoy Rare Pharmacy and will vary based on those needs/priorities.

Physical Demands
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands and fingers, handle or feel; and reach with hands and arms.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function of the job.