Senior Reimbursement Case Manager

From Intake to Outcomes, CareMetx is dedicated to supporting the patient journey by providing hub services, innovative technology, and decision-making data to pharmaceutical, biotechnology, and medical device innovators.

Job Title: Sr. Reimbursement Case Manager

Position Summary:

Under the general supervision of the Supervisor and Director, the Senior Reimbursement Case Manager is responsible for customer service and case management. The Senior Reimbursement Case Manager will work interactively with patients, healthcare providers, specialty pharmacies, and manufacturer clients. The team will also support various reimbursement functions including but not limited to benefits investigations, prior authorization support and call triage. Responds to all patient, nursing, and provider account inquiries. Documents all provider, payer, and client interactions into the CareMetx Connect system in compliance with HIPAA regulations.

Primary Duties and Responsibilities:

• Acts as a single point of contact and voice for all providers, patients and product/sales team.
• Handles escalated accounts and issues.
• Manages special projects and tasks.
• Serves as a patient advocate and enhances the collaborative relationship between the payer, HCP and patient.
• Coordinates access to therapies, conducts appropriate follow up and facilitates access to appropriate support services.
• Manages a regional case load.
• Collect and review all patient insurance benefit information, to the degree authorized by the SOP of the program.
• Provide assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications in a timely manner.
• Track and follow up on prior authorization and appeal requests when necessary.
• Provide exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
• Maintain frequent phone contact with provider representatives, third party customer service representatives and pharmacy staff.
• Report any reimbursement trends/delays to the supervisor.
• Process any correspondence.
• Provide all necessary documentation required to expedite prior authorization requests including demographic, authorization/referrals, National Provider Identification (NPI) number and referring physicians.
• Coordinate with inter-departmental associates as necessary.
• Communicate effectively with payors to ensure accurate and timely benefit investigations.
• Work on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercise judgment within defined standard operating procedures to determine appropriate action.
• Typically receives little instruction on day-to-day work, general instructions on new assignments.
• Must be knowledgeable of HIPAA regulations and HIPAA compliant at all times.
• Other duties as assigned - Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Experience and Educational Requirements:

• Previous 3+ years of experience in a physician’s office, healthcare setting, and/or insurance background preferred.
• Bachelor’s Degree Preferred.

Minimum Skills, Knowledge and Ability Requirements:

• Excellent verbal and written communication skills
• Ability to multi-task and adapt to changing priorities
• Proficient keyboard skills
• Competency in MS Word and Excel
• Knowledge of HIPAA regulations
• Detailed oriented and highly organized
• Excellent interpersonal skills
• Knowledge of pharmacy benefits, and medical benefits.
• Global understanding of commercial and government payers preferred
• Ability and initiative to work independently or as a team member
• Ability to problem solve.

Physical Demands

 The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to sit
• The employee must occasionally lift and/or move up to 10 pounds.

 Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Schedule

 ? Must be flexible on schedule and hours ? Extensive travel is required (60% travel)  

CareMetx considers equivalent combinations of experience and education for most jobs. All candidates who believe they possess equivalent experience and education are encouraged to apply.

At CareMetx we work hard, we believe in what we do, and we want to be a company that does right by our employees. Our niche industry is an integral player in getting specialty products and devices to the patients who need them by managing reimbursements for those products, identifying alternative funding when insurers do not pay, and providing clinical services.

CareMetx is an equal employment opportunity employer. All qualified applicants will receive consideration for employment and will not be discriminated against based on race, color, sex, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, ancestry, or national or ethnic origin.

In addition to above Job Description, the below will be additional Job Requirements that are part of this role:

Additional Role Expectations:

• Single point of contact for provider, patients, 3rd party vendors and manufacturer field teams.
• Process any correspondence. received via the Clients CRM application in a timely manner, including documentation and categorization of correspondence within CareMetx’s CRM.  
• Responsible for coordinating product access and acquisition through benefit verifications, prior authorization and appeals support, assessment for eligibility to client and foundation support programs, pharmacy access identification, etc.
• Provides timely resolution support to escalations received from patients, providers and manufacturer field teams, which may be related to product access, payer claims denial, etc. 
• Subject matter expert on the payer landscape related to applicable disease state and apply it to key trends happening in assigned territory/region. Initiates timely communication with client field team to ensure clarity around reimbursement and access barriers. 
• Collaborates with manufacturer field teams on patient and provider recovery efforts as appropriate
• Responsible for completing targeted patient and provider outreach to educate on program service offerings, available financial and foundation support, etc.
• Work on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercise judgment within defined standard operating procedures to determine appropriate action. 
• Typically receives little instruction on day-to-day work, general instructions on new assignments. 
• Occasional non-customer-facing travel, less than 5% of the time