Clinical Case Manager

Brief Description:  

Performs as a Clinical Case Manager supporting healthcare providers and patients through telephonic support for client funded contracts.  This includes: telephonic support to healthcare providers, review of payor specific coverage criteria, completing clinical review of prior authorization and appeal submissions and providing written communication utilizing client approved program resources. This role will build and develop strong customer relationships and support all activities that facilitate patient access.

Specific job duties:

• Adhere to principles as stipulated by program specific contractual agreements and company practices.
• Demonstrate clinical competency regarding reimbursement, product, and medical records and will review and train other team members on these concepts. 
• Troubleshoot complex cases, identify trends (spanning multiple disease-states), investigate data, and resolve escalated issues related to complex reimbursement from both internal and external stakeholders including prior authorization denials and/or appeals. 
• Perform review of payer product coverage criteria and denial letters for documentation required for submission for coverage determination.
• Provide consistent and effective communication with healthcare providers, utilizing approved resources, regarding payer coverage criteria and information that is missing for payor submission.
• Professional resource for IB/OB inquiries with focus on data collection, assembling accurate, timely, clear updates and documenting summary of follow up phone calls, patient inquiries, and outcomes including clinical notes and medical record/chart review when applicable.
• Gathers, analyzes, and prepares data for Quarterly Business Reviews (QBRs) and/or client meetings.
• Participates in program specific customer meetings and training sessions. 
• Report Adverse Drug Events that have been experienced by the patient in accordance with manufacturer requirements.
• Attend manufacturer hosted conferences, customer meetings/training, and QBRs as requested (including requests to travel for in-person attendance). 
• Special projects and other duties as assigned.

Supervisory Responsibility:  

NA

Desired Skills and Qualifications:

• Minimum- associate degree and professional nursing license 
• Registered Nurse License in good standing in the state in which you work, telephonic clinical roles are required to have a Compact State License in eligible states; additionally, employee must be willing to obtain Compact State license at such time as their state elects to adopt Compact legislation
• Telephonic clinical roles are required to have a California State License and the employee must be willing to obtain additional Single State Licenses upon request. 
• Previous experience in the PBM and/or healthcare industry 
• Competent ability to research, analyze, prepare reports, and document clearly 
• 2+ years’ experience in a customer service setting demonstrating advanced skills in issue resolution, preferably in a call center environment 
• Proficient in Microsoft Office applications, specifically Excel  
• Ability to handle a fast-paced environment and multi-tasking
• Strong written and verbal communication skills 
• Advanced problem solving and trouble-shooting skills including critical thinking
• Strong attention to detail and relationship building skills and the ability to train other team members