Reimbursement Case Manager

Summit Access Solutions,LLC•Coraopolis, PA

5d•Hybrid

About The Position

The Reimbursement Case Manager is a professional client-facing role responsible for various functions related to supporting patients, healthcare providers, and business partners with circumstances related to pharmacy reimbursements. This includes accurate and timely response to client inquiries regarding specific referral status or escalation. The Reimbursement Case Manager serves as a primary point of contact for professional, concise internal and external communication regarding case status updates, next steps in prescription processing, and communication of reimbursement issues. The Reimbursement Case Managers may interact directly with external clients such as manufacturers as well as internal teams including Operations and Program Management. The Reimbursement Case Manager will report to the Program Manager.

Requirements

High school diploma or equivalent
2+ years of relevant pharmacy reimbursement/insurance experience, including benefit investigation and benefit verification of prescription benefits
2+ years of relevant pharmacy case management experience
Working knowledge of BI/BV process, pharmacy and prescription benefits, prior authorization process, and pharmacy access support solutions
Ability to communicate in a clear, logical, effective, and consistent manner
Ability to independently manage case load, prioritize work, and use time management skills to manage deliverables
Empathy, drive, and commitment to exceptional service

Nice To Haves

Associate’s Degree or Bachelor’s Degree
Understanding of plan types – Government, Commercial, Medicaid, VA, Fed
1+ years experience as a pharmacy technician
1+ years experience operating in CareTend Pharmacy Management System
Possess a strong understanding of biologic/specialty pharma market and patient access challenges
Knowledge of insurance structure (ex PBM’s, major medical plans, co-pay assistance /cards)
Working Knowledge of Third-Party and other Foundation programs
Basic understanding of Co-Pay Assistance (if applicable)
Strong analytical and organizational skills with attention to detail
Excellent verbal and written communication skills
Ability to proficiently use Microsoft Excel, Outlook and Word
Knowledge of Rare Diseases
Experience documenting requirements, creating training materials and working directly with end users
Self-starter with ability to exercise sound independent judgment

Responsibilities

Serve as primary point of contact and case manager for client and customer inquiries and escalations
Process benefits investigations, benefits verifications, prior authorization submissions, and appeals as necessary to accelerate patient care access
Coordinates services with internal program operations and Program Management
Ability to coordinate and collaborate with manufacturer representatives, HCP offices and other key personnel on complex cases which require prior authorization or appeals support
Manage patient claims for prescription drug and medical benefits in relation to providing excellent specialty pharmacy care
Establish self as regional expert on payer trends, product access, and reporting reimbursement trends and/or delays (i.e. denials, underpayment, access delays, etc.)
Work independently to complete assigned working accordance with Standard Operating Procedures and defined service levels to complete program enrollment, answer inquiries, and coordinate access to therapies
Process of patient and prescriber requests in order to ensure access to therapy in a timely manner
Use high-level problem-solving skills to research cases independently, using professional judgement to make sound decisions
Maintain frequent phone contact with internal operational staff, external client, and external specialty pharmacies
Provide exceptional, white glove, customer service to internal and external customers; resolves any customer and client requests in a timely and accurate manner; escalates appropriately
Provide support to ensure efficient referral processing from referral intake to triaging of prescription
Independently and effectively resolve complex issues related to pharmacy reimbursement and patient support with creativity and innovation
Strong compliance mindset, demonstrating clear understanding of patient privacy laws
Active participation in building and maintaining respectful, collaborative internal/external team relationships, exercising and encouraging positivity.
Experience supporting complex specialty branded generics