Reimbursement Case Manager, Patient Services

For the past 20 years, ProPharma has improved the health and wellness of patients by providing advice and expertise that empowers biotech, med device, and pharmaceutical organizations of all sizes to confidently advance scientific breakthroughs and introduce new therapies. As the world’s largest RCO (Research Consulting Organization), ProPharma partners with its clients through an advise-build-operate model across the complete product lifecycle. With deep domain expertise in regulatory sciences, clinical research solutions, quality & compliance, pharmacovigilance, medical information, and R&D technology, ProPharma offers an end-to-end suite of fully customizable consulting solutions that de-risk and accelerate our partners’ most high-profile drug and device programs.

The Patient Services Reimbursement Case Manager plays a pivotal role in ensuring patients receive timely access to their prescribed medications while expertly navigating complex reimbursement processes. This role goes beyond reimbursement coordination to include patient intake, customer service, and ongoing support, all with a strong focus on patient-centric care. This role will be instrumental in providing compassionate and personalized support to patients, addressing their unique needs and concerns throughout their treatment journey.

Essential Functions:

Reimbursement Coordination:

• Benefits Verification: Verify patients’ insurance coverage (both medical and pharmacy benefits), co-pays, and eligibility for reimbursement programs.
• Prior Authorizations: Initiate and manage prior authorizations, collaborating closely with patients, prescribers and insurance companies.
• Appeals Support: Guide patients and prescribers through the appeal process, ensuring they have the necessary information and documentation. Collaborate with healthcare providers, insurance companies, and patients to resolve denied claims and secure optimal reimbursement.
• Financial Assistance Programs: Help patients access co-pay assistance, manufacturer support, patient assistance programs, and alternate funding options.

Patient Intake and Onboarding:

• New Patient Intake: Receive and process new patient referrals and gather necessary information for enrollment.
• Welcome Calls: Reach out to newly enrolled patients, providing information about the program and addressing any initial questions or concerns.
• Documentation: Maintain accurate records of patient intake details.

Customer Service and Support:

• Inbound Calls: Handle incoming calls from patients, healthcare providers, and pharmacies.
• Patient Inquiries: Address patient inquiries related to reimbursement, benefits, and program details.
• Problem Resolution: Resolve issues promptly, ensuring a positive patient experience.
• Refill Requests: Process refill requests from existing patients, coordinating with specialty pharmacies.

Collaboration and Communication:

•  Stakeholders: Partner with stakeholders (Sales, Specialty Pharmacies) to develop strategic approaches for reimbursement support.
• Client Field Team: Communicate with client field representatives to address patient access issues.
• Healthcare Providers (HCPs): Collaborate with HCPs to streamline reimbursement processes.

Patient Advocacy and Education:

• Advocate for Patients: Ensure patients receive maximum reimbursement benefits.
• Educate Patients: Explain reimbursement processes, co-pay options, and financial assistance programs.
• Empower Adherence: Emphasize the importance of medication adherence for successful outcomes.

Quality Assurance and Compliance:

• Adherence to Policies: Follow established protocols, guidelines, and compliance standards.
• Audit Documentation: Maintain accurate and complete records for audits and reporting.

Additional Duties:

• Other duties as assigned.

Necessary Skills and Abilities:

• A strong understanding of healthcare systems, patient support services, and relevant regulations is crucial. Familiarity with disease states, treatment pathways, and patient journeys is essential.
• Strong knowledge of reimbursement (both medical and pharmacy benefits) access programs and financial assistance programs
• Excellent verbal, written communication and relationship-building skills. Collaborate with various stakeholders, including healthcare providers, payers, patients/caregivers, and internal teams.
• Proficiency in using Patient Management Applications, preferably Salesforce and other database systems.
• Strong problem-solving skills are essential to address issues promptly when encountering challenges related to patient access, reimbursement, and compliance.
• Ability to adapt to changes and stay informed about industry trends and adjust strategies accordingly as the healthcare landscape evolves rapidly.
• Flexibility adapting to changing business priorities and requirements.
• Demonstrated ability to provide outstanding customer support.
• Meticulous attention to detail ensuring accuracy and quality.
• Strong organizational and prioritization abilities, capable of multitasking efficiently.
• Strong problem-solving skills to address and resolve issues effectively.
• Ability to work independently and collaboratively within a multidisciplinary team.
• Willingness to work extended or flexible hours to meet client needs.
• Proficient in computer usage and keyboarding skills.
• Skilled in using Microsoft Office applications (Outlook, Word, Excel, PowerPoint).
• Strong ability to work effectively within a team environment.

Educational Requirements:

• Bachelor’s degree in a relevant field such as Healthcare Administration, Business, or a related discipline.
• In lieu of a bachelor’s degree, candidates must possess a minimum of 5-7 years of expertise in patient services, insurance reimbursement, insurance verification, both medical and pharmacy and/or medical coding and billing, and/or pharmacy technician experience.

Licensure Requirement:

• Active Pharmacy Technician License or Certified Pharmacy Technician (CPHT) certification. If not currently licensed, the candidate must secure the necessary licensure within 30 days of hire.

Experience Requirements:

• Minimum of 5 years of experience in patient services/support and access, including patient financial assistance, reimbursement coordination with pharmacy and medical benefits, prior authorizations, appeals, medical coding, coverage policies, and policy management.
• Preferred: Call center experience.

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