Clinical Financial Case Manager Senior Pharmacy Denial Management (S4)

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Job Title:

Clinical Financial Case Manager Senior Pharmacy Denial Management (S4)

Department:

James | Pharmacy Administration

Scope/Position Summary

The Clinical Financial Case Manager – Senior Pharmacy Denial Management is responsible for managing complex pharmacy-related medication denials across the health system. Key duties include conducting comprehensive clinical reviews, submitting and tracking appeals, and ensuring timely resolution in alignment with payer guidelines. This role serves as a liaison between the pharmacy department and third-party payors, advocating for optimal reimbursement and resolving technical denials.

The position requires expertise in navigating electronic medical records, interpreting clinical and billing data, and applying recognized clinical guidelines to support appeals. Additional responsibilities include leading process improvement initiatives, mentoring staff, and collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity.

Minimum Qualifications

Minimum 6 years’ experience or relevant healthcare experience required. Bachelor’s degree required. Advanced degree in healthcare or similar field preferred. Experience in finance, insurance, insurance appeals, medication and medical terminology desired. Ability to communicate clearly with others and experience with Microsoft Office, electronic medical records, and intranet/internet navigation tools. Must be highly organized, detail oriented, and able to manage multiple projects at a time. Advanced knowledge of Medicare and commercial insurance reimbursement expected along with strong knowledge of ICD-10 codes. Knowledge in drug billing/coding and reimbursement desired. Excellent verbal and written communication skills desired. Advanced competency in the use of computer-based research and medical record documentation desired

Additional Information:

Location:

Remote Location

Position Type:

Regular

Scheduled Hours:

40

Shift:

First Shift

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