Reimbursement Case Manager

Summit Access Solutions,LLC•Coraopolis, PA

About The Position

The Reimbursement Case Manager is a client-facing professional who supports patients, healthcare providers, and business partners with pharmacy reimbursement matters. The role responds accurately and promptly to client inquiries about referral status and escalations, and serves as a primary contact for concise internal and external communication about case updates, prescription-processing next steps, and reimbursement issues. The position interacts with external clients, including manufacturers, and internal Operations and Program Management teams. It reports to the Clinical Pharmacist and Implementation Manager. The role supports referral processing from intake through prescription triage and helps coordinate timely access to therapy. The position works independently under Standard Operating Procedures and defined service levels, while providing responsive, compliant, and customer-focused case management. Work takes place in a professional office environment and through teleworking from the employee’s home address on file. The amount of time spent in the office or teleworking depends on company needs. Remote work requires reliable internet access and a private, separate home workspace; the employee is responsible for setting up that workspace. Standard office equipment is used. The role’s expected work time does not change when teleworking.

Requirements

High school diploma or equivalent.
At least 2 years of relevant pharmacy reimbursement or insurance experience, including benefits investigation and benefits verification for prescription benefits.
At least 2 years of relevant pharmacy case management experience.
At least 1 year of experience as a pharmacy technician.
At least 1 year of experience using the CareTend Pharmacy Management System.
Working knowledge of the benefits investigation and verification process, pharmacy and prescription benefits, prior authorization processes, and pharmacy access support solutions.
Ability to communicate clearly, logically, effectively, and consistently.
Ability to independently manage a caseload, prioritize work, and use time-management skills to meet deliverables.
Empathy, drive, and commitment to exceptional service.

Nice To Haves

Associate’s or bachelor’s degree.
Understanding of government, commercial, Medicaid, VA, and federal plan types.
Strong understanding of the biologic and specialty pharmaceutical market and patient access challenges.
Knowledge of insurance structures, including pharmacy benefit managers, major medical plans, and copay assistance cards.
Working knowledge of third-party and other foundation programs.
Basic understanding of copay assistance, if applicable.
Strong analytical and organizational skills with attention to detail.
Excellent verbal and written communication skills.
Proficiency with Microsoft Excel, Outlook, and Word.
Knowledge of rare diseases.
Experience documenting requirements, creating training materials, and working directly with end users.
Self-starter with the ability to exercise sound independent judgment.

Responsibilities

Serve as the primary point of contact and case manager for client and customer inquiries and escalations.
Process benefits investigations and verifications, prior authorization submissions, and appeals to help accelerate patient access to care.
Coordinate services with internal program operations and Program Management.
Collaborate with manufacturer representatives, healthcare provider offices, and other personnel on complex cases requiring prior authorization or appeals support.
Manage patient claims for prescription drug and medical benefits in support of specialty pharmacy care.
Develop regional expertise on payer trends and product access, and report reimbursement trends or delays, including denials, underpayments, and access delays.
Complete assigned work independently according to Standard Operating Procedures and service levels, including program enrollment, inquiry responses, and therapy-access coordination.
Process patient and prescriber requests to ensure timely access to therapy.
Research cases independently and use professional judgment and problem-solving skills to make sound decisions.
Maintain frequent phone contact with internal operational staff, external clients, and external specialty pharmacies.
Provide exceptional customer service to internal and external customers, resolve requests accurately and promptly, and escalate appropriately.
Support efficient referral processing from referral intake through prescription triage.
Resolve complex pharmacy reimbursement and patient support issues independently, using creativity and innovation.
Apply a strong compliance mindset and understanding of patient privacy laws.
Build and maintain respectful, collaborative internal and external team relationships, exercising and encouraging positivity.