Managing complex pharmacy-related medication denials across the health system
Conducting comprehensive clinical reviews
Submitting and tracking appeals
Ensuring timely resolution in alignment with payer guidelines
Serving as a liaison between the pharmacy department and third-party payors
Advocating for optimal reimbursement and resolving technical denials
Leading process improvement initiatives
Mentoring staff
Collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity

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

Senior Clinical Financial Case Manager, Pharmacy Denial Management

Key skills