Reimbursement Case Manager

McKesson•Cary, NC

6d•Hybrid

About The Position

The Reimbursement Case Manager serves as the primary liaison between patients, caregivers, healthcare providers, payers, specialty pharmacies, manufacturers, and internal hub teams to facilitate timely access to prescribed therapies. This role is responsible for reimbursement support, patient access services, and case management activities throughout the patient journey. The Reimbursement Case Manager conducts benefit investigations, prior authorization support, appeals coordination, and financial assistance program enrollment while providing high-touch support to patients and healthcare providers. This position works in a fast-paced, high-volume environment and is responsible for identifying and overcoming reimbursement barriers, coordinating patient support services, and ensuring a seamless experience from referral through treatment initiation and ongoing therapy support. Reporting to the Supervisor of Hub Services, the Reimbursement Case Manager regularly interfaces with patients, providers, insurance companies, specialty pharmacies, manufacturer representatives, and internal support teams.

Requirements

Typically requires 5+ years of related experience.
High School Diploma or equivalent required.
2 years of experience in reimbursement, patient access, specialty pharmacy, healthcare operations, medical billing, physician office support, insurance verification, claims adjudication, or pharmaceutical HUB services.
Experience conducting benefit investigations and verifying medical and pharmacy benefits.
Prior authorization and appeal support experience.
Direct customer service, patient support, case management, or provider support experience.
Working knowledge of commercial, Medicare, and Medicaid benefit structures preferred.
Experience in healthcare reimbursement, insurance verification, benefit investigations, patient access, specialty pharmacy, pharmaceutical manufacturer HUBs, medical billing, or claim adjudication.
Strong understanding of medical and pharmacy benefit structures and payer coverage requirements.
Experience supporting prior authorizations, appeals, financial assistance programs, and reimbursement processes.
Knowledge of specialty medications and the relationship between manufacturers, payers, specialty pharmacies, and healthcare providers.
Ability to manage a high-volume caseload while maintaining accuracy and attention to detail.
Excellent customer service, communication, and relationship-building skills.
Strong organizational and time management skills.
Proficiency with CRM systems (Salesforce preferred) and Microsoft Office Suite.
Strong interpersonal and communication skills; able to engage empathetically with patients and caregivers
Knowledge of commercial, Medicare, and Medicaid insurance programs.
Understanding of prior authorization processes, appeals, reimbursement methodologies, and specialty pharmacy workflows.
Familiarity with ICD-10, HCPCS, and CPT coding preferred.
Strong analytical, problem-solving, and critical-thinking skills.
Ability to effectively prioritize and manage multiple responsibilities in a fast-paced environment.
Knowledge of HIPAA, patient privacy, and healthcare compliance requirements.
Ability to communicate complex reimbursement information in a clear and concise manner.
Ability to work independently and collaboratively across internal and external teams.

Nice To Haves

Associate’s degree preferred

Responsibilities

Contact commercial, Medicare, Medicaid, and other payers to verify patient eligibility, benefits, and product-specific coverage information.
Conduct comprehensive benefit investigations, including verification of medical and pharmacy benefits, patient financial responsibility, and coverage requirements.
Obtain payer-specific prior authorization requirements, coverage criteria, documentation requirements, and utilization management guidelines.
Coordinate and facilitate prior authorization submissions with healthcare providers and payer organizations.
Monitor authorization status and proactively follow up with providers, payers, and specialty pharmacies to obtain timely determinations.
Assist with appeal submissions, reconsiderations, and coverage exception requests for denied therapies.
Provide reimbursement support, including claims assistance, billing guidance, and coding information to provider offices as appropriate.
Research and maintain payer-specific reimbursement information and coverage requirements within internal systems and reimbursement databases.
Serve as the single point of contact for patients, caregivers, and healthcare providers throughout the patient journey.
Coordinate patient enrollment into manufacturer-sponsored HUB programs and support services.
Educate patients and provider offices regarding reimbursement processes, insurance requirements, and available support services.
Assess patient needs and facilitate enrollment into financial assistance programs, including copay assistance, patient assistance programs (PAP), bridge programs, and quick-start programs.
Monitor patient progress through the treatment pathway and proactively address barriers that may impact therapy initiation or continuation.
Provide accurate and timely follow-up on reimbursement inquiries and case-related activities in accordance with program requirements and service level expectations.
Collaborate with provider offices to obtain required prescriptions, referrals, clinical documentation, and supporting medical records.
Coordinate patient triage and product distribution with specialty pharmacies, infusion centers, and healthcare providers.
Facilitate communication between providers, pharmacies, payers, and manufacturer partners to support timely access to therapy.
Resolve issues related to coverage, authorization, prescription fulfillment, and treatment coordination.
Ensure all referral and intake information is accurate and complete to support reimbursement activities.
Accurately document all case activities, payer communications, authorizations, assistance program enrollment, and patient interactions within designated systems.
Maintain compliance with HIPAA, manufacturer program requirements, company policies, and applicable regulatory guidelines.
Adhere to established SOPs, work instructions, quality standards, and program requirements.
Partner with internal HUB teams, field reimbursement managers, pharmacy operations, patient support services, manufacturer partners, and leadership to resolve complex patient access issues.
Escalate reimbursement, access, or operational concerns appropriately.
Support process improvement initiatives and contribute to program performance goals.
Maintain current knowledge of payer policies, reimbursement trends, specialty pharmacy processes, and patient access programs.