Claims Manager Jobs

About The Position

Requirements

• Experience in specialty pharmacy, patient support programs, reimbursement, insurance, claims, accounts receivable or operational analysis.
• Strong understanding of private insurance, RAMQ, special authorizations, copay cards, financial assistance programs and billing issues related to high-cost medications.
• Experience with Kroll is strongly preferred.
• Strong Excel skills and ability to analyze Power BI reports; direct Power BI experience is considered a strong asset.
• Comfort working with multiple technology platforms, including Xero, SAP Ariba, PSP/manufacturer portals and internal systems.
• Ability to coordinate, delegate and follow up on the work of reimbursement specialists or pharmacy technicians.
• Excellent organizational skills, high level of accuracy and strong attention to detail.
• Ability to manage several complex files simultaneously and prioritize based on patient, operational and financial risk.
• Excellent verbal and written communication skills in French and English.
• Self-starter with strong judgment, proactivity and ability to work with a high degree of independence.

Nice To Haves

• Your commitment to providing a high level of service to your internal and external clients.
• You are highly adaptable with a track record of success during times of growth and organizational change.
• You have a proven track record of developing trust and influence at multiple levels.
• You demonstrate an impactful and candid communication style.
• You have exceptional organizational skills with the ability to build effective working relationships with colleagues, management, and stakeholders.

Responsibilities

• Manage and monitor claims related to specialty medications, patient financial assistance and amounts advanced by the pharmacy.
• Verify that medications have been approved by public or private insurers before billing or dispensing, when required.
• Identify files where insurance approval is missing, denied, incomplete, expired or inconsistent with billing requirements.
• Perform the required follow-up with insurers, manufacturers, PSPs or other stakeholders, and delegate tasks to reimbursement specialists when appropriate.
• Oversee delegated reimbursement files until resolution, including special authorizations, renewals, denials, appeals, missing documents and processing delays.
• Analyze Power BI reports to identify billing errors, payment discrepancies, amounts to be claimed, unreimbursed amounts and high-risk files.
• Validate information in Kroll, including insurance coverage, third-party payer restrictions, applicable codes, benefit coordination, patient amounts and service dates.
• Direct necessary corrections to pharmacy technicians, provide clear instructions and confirm that transactions have been corrected appropriately.
• Submit reimbursement claims to manufacturers or PSPs, including through PSP portals, SAP Ariba or any other applicable platform.
• Collaborate with the accounting team to reconcile amounts receivable, reimbursements received and related entries in Xero.
• Maintain structured tracking by patient, medication, manufacturer, program, insurer, amount receivable and reimbursement status.
• Develop, write, implement and maintain procedures, job aids, quick-reference guides, instructions, checklists and other documentation related to reimbursement, financial assistance submissions, claims management and related workflows.
• Prepare periodic follow-ups on open claims, pending amounts, reimbursement delays, identified discrepancies and recurring issues.
• Escalate problematic files promptly in order to limit financial losses, treatment delays and patient access issues.
• Participate in the continuous improvement of procedures, tracking tools, Power BI reports and claims/financial assistance workflows.
• Maintain patient confidentiality and comply with internal policies, SOPs and applicable regulatory requirements.
• Perform any other administrative, operational or related duties that may be required as part of the role and responsibilities assigned by management.

Benefits

• Competitive salary
• OPQ and FARPOPQ contributions paid.
• Health insurance fully paid by the employer
• RRSP contribution by the employer
• allowance of $1000/year for continuing education.