Executive Case Manager

Mercalis

19h•Onsite

About The Position

The Executive Case Manager provides expertise on insurance coverage and common access and reimbursement challenges affecting patients, healthcare providers and clients. The Executive Case Manager responsibilities include education on the access and reimbursement support tools available from PharmaCord and participating program, advising HCPs and/or patients and caregivers on the benefits and program eligibility for a specific patient, and educating HCP offices on Payor processes and procedures.

Requirements

Completion of Bachelor's degree (or higher) required. Degree in healthcare administration, social science or similar related fields is strongly preferred. In lieu of a degree, five plus years of experience in insurance reimbursement, patient access, direct patient care, and/or patient education is required.
Two years of experience in insurance reimbursement, patient access, direct patient care, and/or patient education is required.
Strong understanding of medical terminology, coding systems (ICD-10, CPT, HCPCS), and insurance processes.
Demonstrated examples of executing within guardrails recognizing urgency and consistently delivering patient centric results.
Excellent attention to detail and organizational skills.
Ability to prioritize tasks and work efficiently in a fast-paced environment.
Effective written and verbal communication and interpersonal skills, with the ability to interact professionally with diverse stakeholders.
Demonstrates the ability to think critically and issue resolution.

Nice To Haves

Minimum two years of experience in healthcare access delivery or management is strongly preferred.
Will consider other certifications and five or more consecutive years of experience in relevant field. Certification examples include PACS (Prior Authorization Certified Specialist), CHES (Certified Health Education Specialist) or CCM in healthcare or social science (Certified Case Manager).
Prefer candidates who can type at least 35 words per minute with 97% accuracy.
flexibility to travel as needed is preferred.

Responsibilities

Builds trusted relationships with patients, prescribers, and appropriate client stakeholders regarding reimbursement inquiries and challenges through proactive communication, timely and accurate execution of deliverables and demonstrated relentless passion for helping patients.
Manages all relationships in a manner that adheres to all relevant laws, regulations, program-specific operating procedures and industry standards related to access and affordability, including HIPAA and insurance guidelines.
Managed through call/contact center structure, this role supports inbound and outbound calls to patients, caregivers, specialty pharmacies and healthcare professionals.
Performs post Benefits Investigation calls to patients and/or physicians explaining coverage options and next steps in the access journey.
Manages all client inquiries as appropriate, such as case specific statuses.
Manages HCP inquiries, as applicable, pursuant to business rules.
All communications with the client’s field teams will remain compliant and adhere to ways of working protocols outlined between PharmaCord and the client teams.
Manages inbound calls as directed by the program-approved FAQs
Triage patients to internal or external resources as appropriate.
Provides personalized case management to patients and HCPs including outbound communication to HCPs, specialty pharmacies and patients to communicate benefit coverage and/or appropriately help drive next steps in obtaining coverage and/or access to prescribed medicine. All communications for case management will follow the guidelines set forth for the program and only provide information publicly available and/or outlined in the patient insert.
Leverages electronic tools to identify benefits and payer coverage; completes manual benefit investigation as needed.
Identifies and communicates patient’s plan benefit coverage including the need for prior authorization, appeal, tier exception, and/or formulary exclusions.
Serves as a subject matter expert to internal team as required and appropriate.
Uses electronic resources to obtain benefit coverage outcome and if needed, outbound call to payers and HCPs to follow up on proper submission and/or outcome.
Coordinates nurse teach with nurse educators, as applicable to program.
Supports adherence services as applicable to program.
Identifies peer support resources for patients.
Proactively communicates needs for reverification of prior authorization or re-enrollment.
Identifies and reports adverse events, product complaints, special situation reports and/or medical inquiries received in accordance with program operating procedures and the Business Rules.
Documents all activities within the PharmaCord Lynk system, maintaining detailed records of reimbursement activities, including claims status, payments, and appeals.
Generate reports and analysis as needed to identify trends and opportunities for improvement.in accordance with business require
Utilize Valeris’ values as the driving force behind the team’s success
On time adherence to training deadlines for all corporate policies and procedures
Ensure all SOPs are followed with consistency
Perform additional tasks or projects as assigned

Benefits

Medical, dental, and vision plans, including HSA- and FSA-eligible options, with Valeris contributing toward premium costs
Additional health support, including telehealth and Employee Assistance Program (EAP) services
Company match on Health Savings Account contributions
Free Basic Life and AD&D coverage equal to your annual earnings, with a minimum of $50,000 and a maximum of $300,000
Company-paid Short-Term Disability coverage, with the option to purchase Long-Term Disability
401(k) Retirement Savings Plan with 100% match on the first 5% you contribute, with immediate vesting
Paid Time Off (PTO) and Sick Leave to support work-life balance
Team members receive nine paid holidays plus two floating holidays
Opportunities for advancement in a company that supports personal and professional growth
A challenging, stimulating work environment that encourages new ideas
Work for a company that values diversity and makes deliberate efforts to create an inclusive workplace
A mission-driven, inclusive culture where your work makes a meaningful impact