Case Manager

Case Manager

The Case Manager's primary duty is to assist customers with chronic illnesses in their assigned territory by accessing their well-being needs, journey, and treatment plan.

The Case Manager collaborates and maintains consistent communications with internal and external partners (Pharma Reps, Doctor offices, or Insurance companies) to formulate, affect, and interpret operational practices to achieve resolution based on last-stop coordination concerns.

Case Managers use discretion for timely case resolution and maintain compliance based on matters of significance.

The incumbent utilizes care coordination to address patient and physician concerns and obtains insurance approval for designated therapy and proactive plans to avoid the potential of delayed coverage by working with the patient, family, insurance, company, physicians, workplace, benefits administrators, and individuals from other areas.

The Case Manager facilitates the case management process along the healthcare continuum, advocating and contributing to the patient's positive journey.

Facilitate the case management process along the healthcare continuum. The incumbent assists with Benefit Investigations upon program need.

Takes the lead in managing the Care Coordination process within an assigned territory. Uses tact and independent judgment to balance patient and physician needs with the business realities and necessities of the program. Establishes and maintains professional and effective relationships with all internal and external customers (i.e., care coordination colleagues, care field team, patient advocacy groups, insurance company case managers, specialty pharmacies, physician office staff, and office coordinators) while multitasking to coordinate, evaluate and advocate for options and services to meet the client's needs.

Assesses physicians' needs and develops action plans that proactively mitigate delays in therapy. Coordinates exchanging all patient-related information with internal and external customers (i.e., patients, families, healthcare providers, insurance companies, and specialty pharmacies). Effectively manages the database, including data on each individual, their insurance, coverage approvals, ongoing coverage requirements, and all patient and provider interactions.

Keeps up to date with reimbursement process, billing/coding nuances, insurance plans, payer trends, financial assistance programs, charitable access, related resources, regional level, and alternative resources.

Assists in obtaining insurance approvals/denials and/or appeals for therapy. Assists patients and HCPs with processing Copay Assistance/Reimbursement and Patient Assistance Programs applications. Helps with ordering/triaging prescriptions for patients or HCPs.

Provides education to patients and health care providers regarding insurance requirements, options, and limitations necessary to initiate therapy. Provides education on relevant disease/product information.

Exhibits a leadership role by demonstrating accountability for action plan execution and energetically drives for success and results. Supports special projects as requested. (i.e., patients, families, healthcare providers, insurance companies, and specialty pharmacies).

Identifies and recommends process improvements to support operational efficiencies. Effectively shares knowledge with other team members through orientation training, case studies, and consultation for complex cases.

Bachelor's Degree (or equivalent) in a related area focusing on Health Care, Social Work, or Nursing, preferred. Minimum 3 years of recent experience in the case management process preferred. Proven ability to assess the ethics and legality of patient's care. Experience in home care management, case management review, utilization review, social service support, insurance reimbursement, and patient advocacy, preferred. In-depth understanding of health care insurance benefits, relevant state and federal laws, and insurance regulations, highly desired. Experience with data entry/computer literate skills preferred. Exhibits a high level of case management expertise and demonstrated leadership skills. Strong verbal and written communication skills, including effectively communicating with clients/providers/patients and employees professionally and courteously. Mediation and problem-solving skills. The ability to speak Spanish is a plus. Ability to identify and handle sensitive issues with opposing opinions. Proven ability to work independently and handle projects or multiple tasks. Must possess the core values of Passion, Innovation, Integrity, and Accountability.