Case Manager

Overview

The Case Manager’s primary duty is to assist customers with chronic illnesses in their assigned territory by gaining access to their wellbeing needs, journey and treatment plan. The Case Manager collaborates and maintains consistent communications with internal and external partners (Pharma Reps, Doctor offices or Insurance companies) to formulate, affect, interpret operational practices to achieve resolution based on last stop coordination concerns. Case Managers use discretion for timely case resolution and maintains compliance based on matters of significance. The incumbent utilizes care coordination to address patient and physician concerns; obtains insurance approval for designated therapy and proactive plans to avoid the potential of delayed coverage by working with the patient, family, insurance, company, physicians, workplace, benefits administrators and individuals from other areas. The Case Manager facilitates the case management process along the healthcare continuum; advocating and contributing to the patient’s positive journey. Facilitate the case management process along the healthcare continuum. The incumbent assists with Benefit Investigations upon program need. 

Responsibilities

• Takes the lead to manage the Care Coordination process within an assigned territory. Uses tact and independent judgment to balance patient and physician needs with the business realities and necessities of the program. Establishes and maintains professional and effective relationships with all internal and external customers (i.e., care coordination colleagues, care field team, patient advocacy groups, insurance company case managers, specialty pharmacies, physician office staff and office coordinators) while multitasking to coordinate, evaluate and advocate for options and services to meet the client’s needs.
• Assesses physicians’ needs and develops action plans that proactively mitigate delays in therapy. Coordinates the exchange of all patient-related information with internal and external customers (i.e., patients, families, healthcare providers, insurance companies, and specialty pharmacies). Effectively manages database including data on each individual, their insurance, coverage approvals, on-going coverage requirements and all patient and provider interactions.
• Keeps up to date with reimbursement process, billing/coding nuances, insurance plans, payer trends, financial assistance programs, charitable access, related resources, regional level and alternative resources.
• Assists in obtaining insurance approvals/denials and/or appeals for therapy. Assists patients and HCP with processing applications for Copay Assistance/Reimbursement and Patient Assistance Programs. Assists with ordering/triaging prescriptions for patient or HCP.
• Provides education to patients and health care providers, regarding insurance requirements, options and limitations necessary to initiate therapy. Provides education on relevant disease/product information.
• Exhibits a leadership role by demonstrating accountability for action plan execution, and energetically drives for success and results. Supports special projects as requested. (i.e., patients, families, healthcare providers, insurance companies, and specialty pharmacies).
• Identifies and recommends process improvements to support operational efficiencies. Effectively shares knowledge with other team members through orientation training, case studies, consultation for complex cases.
• Other duties as assigned.

Qualifications

• Bachelor’s Degree (or equivalent) in related area with focus in Health Care, Social Work, Nursing, preferred.
• Minimum of three (3) years of recent experience with health care insurance benefits, relevant state and federal laws, and insurance regulations.
• Proven ability to assess the ethics and legality of patient care.
• Recent experience in the case management process is preferred.
• Experience in a combination of home care management, case management review, utilization review, social service support, insurance reimbursement and patient advocacy, preferred.
• In-depth understanding of health care insurance benefits, relevant state and federal laws and insurance regulations, highly desired.
• Experience with data entry/computer literate skills, preferred.
• Exhibits a high level of case management expertise and demonstrated leadership skills
• Strong verbal and written communication skills, including effectively communicating with clients/providers/patients and employees of ConnectiveRx in a professional and courteous manner. Mediation, and problem-solving skills.
• Ability to speak Spanish is a plus.
• Ability to identify and handle sensitive issues with opposing opinions
• Proven ability to work independently and handle projects or multiple tasks
• Must possess the ConnectiveRx core values of: Passion, Innovation, Integrity, Accountability.