Bethesda, Maryland
Reimbursement Case Manager Job Opening in Bethesda, Maryland - CareMetx is seeking ambitious, motivated individuals with excellent communication, interpersonal and organizational skills who would like the opportunity to help people navigate the difficult healthcare landscape using their healthcare administration or information technology skills.
When patient's are prescribed high cost, specialty medications , organizations like CareMetx are hired by pharmaceutical companies to provide "hub services." This niche industry has fast become an integral player in getting specialty products and devices to the patients who need them by managing the reimbursement for those products, identifying alternative funding when insurer's don't pay and providing clinical services when necessary. The hub maintains communication with physicians, specialty pharmacies, payers and others to assure patients get their medications in a timely fashion and continue to track progress while they are taking the medication.
POSITION SUMMARY :
Under the general supervision of the Reimbursement HUB Supervisor and Manager, the Reimbursement Case Manager is responsible for customer service and case management. The Reimbursement Case Manager will work interactively with patients, healthcare providers, specialty pharmacies, and manufacturer clients. The team will also support various reimbursement functions including but not limited to benefits investigations, prior authorization support and call triage. Responds to all patient, nursing, and provider account inquiries. Documents all provider, payer and client interactions into the CareMetx Connect system in compliance with HIPAA regulations.
Position Description, Duties and Responsibilities :
Acts as single point of contact and voice for all providers, patients and product/sales team.
Serves as a patient advocate and enhances the collaborative relationship between the payer, HCP and patient.
Coordinates access to therapies, conducts appropriate follow up and facilitates access to appropriate support services.
Manages a regional case load.
Collect and review all patient insurance benefit information, to the degree authorized by the SOP of the program.
Provide assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications in a timely manner.
Track and follow up on prior authorization and appeal request when necessary.
Provide exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly.
Maintain frequent phone contact with provider representatives, third party customer service representatives and pharmacy staff.
Report any reimbursement trends/delays to supervisor.
Process any correspondence.
Provide all necessary documentation required to expedite prior authorization requests including demographic, , National Provider Identification (NPI) number and referring physicians.
Coordinate with inter-departmental associates as necessary.
Communicate effectively with payors to ensure accurate and timely benefit investigations.
Work on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercise judgment within defined standard operating procedures to determine appropriate action.
Typically receives little instruction on day-to-day work, general instructions on new assignments.
Must be knowledgeable of HIPAA regulations and HIPAA compliant at all times.
Perform related duties as assigned.
Minimum Experience and Education Requirements:
Previous 4+ years of experience in a physician?s office, healthcare setting, and/or insurance background strongly preferred. Bachelor?s Degree Preferred.
Minimum Skills, Knowledge, and Ability Requirements:
Excellent verbal and written communication skills.
Ability to multi-task and adapt to changing priorities.
Proficient keyboard skills.
Competency in MS Word and Excel.
Knowledge of HIPAA regulations.
Detailed oriented and highly organized.
Excellent inter-personal skills.
Knowledge of pharmacy benefits, and medical benefits.
Global understanding of commercial and government payers preferred.
Ability and initiative to work independently or as a team member.
Ability to problem solve.
Customer satisfaction focused.
Job Type: Full-time
Required education:
High school or equivalent
Required experience:
Reimbursement experience in a healthcare or physician office: 4 years
identifying payer reimbursement trends: 4 years
in depth knowledge of pharmacy and medical benefits: 4 years
hands on experience with submitting/tracking Prior Authorizations and Appeals: 4 years
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