Clinical Financial Case Manager Senior Pharmacy Denial Management (S4)

The Ohio State University

4d • Remote

About The Position

The Clinical Financial Case Manager – Senior Pharmacy Denial Management is responsible for managing complex pharmacy-related medication denials across the health system. Key duties include conducting comprehensive clinical reviews, submitting and tracking appeals, and ensuring timely resolution in alignment with payer guidelines. This role serves as a liaison between the pharmacy department and third-party payors, advocating for optimal reimbursement and resolving technical denials. The position requires expertise in navigating electronic medical records, interpreting clinical and billing data, and applying recognized clinical guidelines to support appeals. Additional responsibilities include leading process improvement initiatives, mentoring staff, and collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity.

Requirements

• Minimum 6 years’ experience or relevant healthcare experience required.
• Bachelor’s degree required.
• Ability to communicate clearly with others and experience with Microsoft Office, electronic medical records, and intranet/internet navigation tools.
• Must be highly organized, detail oriented, and able to manage multiple projects at a time.
• Advanced knowledge of Medicare and commercial insurance reimbursement expected along with strong knowledge of ICD-10 codes.

Nice To Haves

• Advanced degree in healthcare or similar field preferred.
• Experience in finance, insurance, insurance appeals, medication and medical terminology desired.
• Knowledge in drug billing/coding and reimbursement desired.
• Excellent verbal and written communication skills desired.
• Advanced competency in the use of computer-based research and medical record documentation desired

Responsibilities

• Managing complex pharmacy-related medication denials across the health system.
• Conducting comprehensive clinical reviews.
• Submitting and tracking appeals.
• Ensuring timely resolution in alignment with payer guidelines.
• Serving as a liaison between the pharmacy department and third-party payors.
• Advocating for optimal reimbursement and resolving technical denials.
• Navigating electronic medical records.
• Interpreting clinical and billing data.
• Applying recognized clinical guidelines to support appeals.
• Leading process improvement initiatives.
• Mentoring staff.
• Collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity.

Benefits

• Eligible Ohio State employees receive comprehensive benefits packages, including medical, dental and vision insurance, tuition assistance for employees and their dependents, and state or alternative retirement options with competitive employer contributions.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level