Reimbursement Case Manager

 Purpose:

The Reimbursement Case Manager (RCM) is a professional client facing role responsible for various functions, including accurate and timely response to client inquiries regarding specific referral status or escalation. The RCM serves as a primary point of contact for payers. The RCM will manage the benefits investigation process to determine patient eligibility and coverage per their plan along with prior authorization and appeal support. The RCM will interact indirectly with external clients such as manufacturers and specialty pharmacies as well as internal teams including Operations and Program Management. 

Responsibilities: 

• Serve as primary point of contact for client and customer reimbursement inquiries and escalations.
• Coordinate investigation and determination of patient benefits with internal program operations, insurance plans, and specialty pharmacy liaisons. 
• Review forms for completeness and communicate any missing information required to complete benefit verification process.
• Apply defined business rules to qualify patients for manufacturer supported programs.
• Work independently to complete assigned work in accordance with Standard Operating Procedures and defined service levels to complete benefits verification process, prescription coverage, authorization and appeal support, and answer any reimbursement related inquiries.
• Use high-level problem-solving skills to research cases and resolve independently using creativity, innovation, and professional judgement to make sound decisions. 
• Leverages both electronic and telephonic benefit investigation tools to verify eligibility, coverage, authorization and appeal process, specialty pharmacy mandates, and cost differences. 
• Maintain frequent phone contact with payers to gather all necessary information related to case/patient information, insurance coverage, and where applicable, prior authorization (PA) or appeals processing.

• Maintain clear, concise, and accurate documentation on all accounts according to Standard Operating Procedures.
• Independently and effectively verify coverage and proactively enroll eligible patients into the commercial copay program.
• Efficiently process patient and prescriber requests to accelerate access to therapy.
• Serve as operational expert on payer trends, product access, and reporting reimbursement insights and/or delays, i.e., denials, underpayment, access delays. 
• Frequently communicate with program management on new insurance requirements and trends.
• Provide concierge-level service to internal and external customers; resolve any customer and client requests in a timely and accurate manner; escalate appropriately. 
• Coordinate and collaborate with internal team members to provide reimbursement information to manufacturer representatives, HCP offices and other key personnel.
• 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. 
• This position may require flexibility in scheduling, with shifts occurring between 8:00AM and 8:00PM EST, Monday through Friday. Employees should be prepared to work within this timeframe as needed. 
• Other duties as assigned. 

Required Qualifications: 

• High school diploma plus 2+ years recent reimbursement experience
• Previous 2+ years of experience in a pharmacy, healthcare setting and/or pharmacy/medical insurance background
• Advanced knowledge and experience in healthcare setting
• Experience with benefit investigation and verification of prescription benefits
• Ability to communicate effectively both orally and in writing with a focus on customer satisfaction
• Ability to independently manage case load, prioritize work, and use time management skills to meet deliverables
• Empathy, drive, and commitment to exceptional service
• Strong analytical and organizational skills with attention to detail

• Ability to work flexible schedule per Program business needs
• Strong interpersonal skills; possess effective oral and written communication skills
• Possess a strong understanding of biologic/specialty pharma market and patient access challenges
• Ability to leverage professional expertise
• Apply company policies and procedures to resolve challenges

Preferred Qualifications: 

• Undergraduate Degree and/or equivalent work experience 
• Certified Pharmacy Technician (CPhT)
• Understanding of plan types – Government, Commercial, Medicaid, VA, Fed 
• Knowledge of insurance structure (ex PBM’s, major medical plans, co-pay assistance /cards) 
• Experience with benefit investigation and verification of prescription benefits
• Working Knowledge of Third-Party and other Foundation programs
• Basic understanding of Co-Pay Assistance (if applicable)
• Understanding of HUB patient journey, workflow, and triage is a plus 
• Ability to proficiently use Microsoft Teams, Excel, Outlook, and Word
• Strong analytical and organizational skills with meticulous attention to detail