Clinical Case Manager, RN

Role Overview

• 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.
• 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.

Requirements

• 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

Benefits

• Remote opportunities
• Competitive salaries
• Growth opportunities for promotion
• 401K with company match*
• Tuition reimbursement (after 90 days of employment)
• Flexible work environment
• 20 days PTO
• Paid Holidays
• Employee assistance programs
• Medical, Dental, and vision coverage
• HSA/FSA
• Telemedicine (Virtual doctor appointments)
• Wellness program
• Adoption assistance
• Short term disability (after 90 days of employment)
• Long term disability
• Life insurance
• Discount programs