Hybrid Benefit Investigation Case Manager

at RareMed Solutions

• Job title: Benefit Investigation Case Manager
• Job type: Full Time
• Experience level: Junior, Mid level
• Salary: Not specified
• Degree requirement: High School Diploma
• Location requirements: Hybrid, Coraopolis, United States

About the role

• Benefit Investigation Case Manager at RareMed managing patient eligibility and coverage inquiries. Coordinating with medical professionals and overseeing case management processes.

Responsibilities

• Serve as the point of contact for regionally aligned field team related to cases where Reimbursement Services are requested from Facility.
• Coordinate all BI related support and access services across all functions including patient support, benefits verification and triage to specialty pharmacy.
• Review and add Provider and Facility profile data to capture the key information related to HCP facilities and customers.
• Maintain frequent touchpoints through outreach to providers and patients/caregivers to communicate progress throughout their journey.
• Work independently to complete assigned work in accordance with Standard Operating Procedures and defined service levels to complete Service requests, program enrollment, answer inquiries, coordinate investigation and determination of patient benefits coordinate access to free Supply Program, if applicable.
• Independently and effectively identify adverse events and/or product complaints and triage as appropriate.
• Apply defined business rules to qualify patients for manufacturer supported programs.
• Interact and coordinate with internal program operations, including reimbursement, and program management to ensure provider and patient needs are met in addition to attending any regularly scheduled calls.
• Independently and effectively resolves complex issues with creativity and innovation while maintaining compliance.
• Refer patients to third-party or other foundation programs per program business rules.
• Manage case triage to Specialty Pharmacy or Long-Term Care Pharmacy, if applicable, and ensure proper information has been communicated to the Specialty Pharmacy Liaison.
• Collaborate with SPs and field teams on case recovery efforts.
• Process PAP requests, when applicable per program business rules, in a timely fashion and PAP re-approval verification for continued eligibility.
• Demonstrate the ability to prioritize and balance the needs of patients, LTC facility staff and rare disease clients utilizing program business rules.
• Provide concierge-level service to internal and external customers; resolve any customer and client requests in a timely and accurate manner; escalate appropriately.
• Maintain frequent phone/email contact with internal operational staff, external client, external specialty pharmacies, providers, and payers. Utilizes outbound faxes, email alerts, and mailings per program guidelines.
• Strong compliance mindset, demonstrating clear understanding of patient privacy laws.
• Actively participate in building and maintaining respectful, collaborative team relationships, exercising, and encouraging positivity.
• Other duties as assigned including cross training to support all Regional Patient Case Manager activities when needed.
• Provide support, education, and status updates to regionally aligned field teams, LTC facility staff, HCP offices, patients and caregivers to ensure efficient referral processing, triaging, and shipment set ups.
• Manage assigned territory using problem solving skills and professional judgement to independently make sound decisions for timely case resolution.
• Ability to coordinate and collaborate with manufacturer representatives, LTC facilities, HCP offices, and other key personnel on complex cases which require strategic intervention.

Requirements

• High school diploma plus 2+ years recent case management experience
• Previous 3+ years of experience in a pharmacy, healthcare setting, and/or insurance background preferably in long term care reimbursement or disability care
• Advanced knowledge and experience in healthcare setting
• Strong interpersonal skills; ability to communicate effectively both orally and in writing with a focus on customer satisfaction
• Empathy, drive and commitment to exceptional service
• Ability to build productive internal/external working relationships
• Ability to independently manage case load, prioritize work, and use time management skills to meet deliverables
• Preferred Qualifications: Undergraduate degree and/or equivalent work experience
• Certified Pharmacy Technician (CPhT) or Case Management Experience
• Long-term care reimbursement/case management experience is a major plus
• Bilingual Spanish speaking and writing is plus
• Strong analytical and organizational skills with meticulous attention to detail
• Experience with benefit investigation and verification of prescription benefits
• Working knowledge of Third-Party and other Foundation programs a major plus
• Understanding of plan types – Government, Commercial, Medicaid, VA, Fed
• Knowledge of insurance structure (ex PBM’s, major medical plans, co-pay assistance/cards)
• Ability to proficiently use Microsoft Excel, Outlook, and Word.

Benefits

• RareMed offers a hybrid work structure, combining remote work and in-office requirements.
• Employees must be within commuting distance to Pittsburgh, PA, and able to report to the office when needed.
• We will provide advance notice when possible.
• This role routinely involves standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
• When telecommuting, employees must have reliable internet access to utilize required systems and software required for the position's responsibilities.
• The amount of time the employee is expected to work per day or pay period will not change while working from home.
• Employees are responsible for the set-up of their home office environment, including physical set-up, internet connection, phone line, electricity, lighting, comfortable temperature, furniture, etc.
• Employee’s teleworking space should be separate and distinct from their “home space” and allow for privacy.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function of the job.