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Drug Prior Authorization Case Manager
Manulife. Manage intake, review, and adjudication of Prior Authorization drug requests against clinical guidelines, plan provisions, and documented approval criteria .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Prior Authorization and claims adjudication, with strong analytical and problem-solving skills to manage complex cases and ensure compliance with clinical guidelines. Proficient in communication and collaboration to enhance operational effectiveness and customer experience.
Highest-signal resume keywords
Prior Authorization ManagementClaims AdjudicationAnalytical SkillsCustomer FocusMicrosoft Office 365 Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ManagementCase ManagementBenefits AdministrationMedical TerminologyDental TerminologyRisk AssessmentDecision-MakingProblem-SolvingEscalated Claims ResolutionQuality Assurance
Soft Skills
Excellent Communication SkillsAttention to DetailCollaborationInfluencing SkillsNegotiation Skills
Industry Keywords
Group BenefitsInsuranceRegulated EnvironmentCustomer Contact CentreOperational Effectiveness
About the role
Key responsibilities & impact- Manage intake, review, and adjudication of Prior Authorization drug requests against clinical guidelines, plan provisions, and documented approval criteria
- Own cases from intake through resolution, prioritizing work based on urgency and complexity
- Communicate claim outcomes to members, providers, pharmacies, and internal stakeholders
- Research and analyze complex, escalated, or non-standard claim and authorization scenarios
- Serve as a subject matter expert for Prior Authorization and claims adjudication
- Provide guidance and support to internal teams and outsource partners
- Apply risk management principles and sound judgment when assessing claim requests
- Participate in projects and initiatives improving operational effectiveness, quality, and customer experience
- Manage escalated claims issues for timely and effective resolution
- Support quality assurance, knowledge sharing, training, and continuous improvement initiatives
- Provide direct support to organizational stakeholders and peer training
- Align work coverage with the Customer Contact Centre as needed
Requirements
What you’ll need- Post-secondary education or an equivalent combination of education and relevant experience
- 2-3 years of experience in a customer-focused environment, case management, claims, or a related field
- Proficiency with Microsoft Office 365 applications
- Experience in Group Benefits, claims management, disability management, insurance, or another regulated environment
- Knowledge of benefits administration, medical and dental terminology, or claims-related practices
- Excellent written and verbal communication skills
- Strong analytical, problem-solving, and decision-making skills
- Ability to manage multiple priorities in a fast-paced and evolving environment
- Strong attention to detail, sound judgment, and commitment to maintaining confidentiality
- Ability to work independently while collaborating effectively within a team environment
- Experience investigating complex cases, assessing risk, and resolving challenging situations
- Strong customer focus and ability to build productive relationships with a wide range of stakeholders
- Strong influencing, negotiation, collaboration, and communication skills
- Ability to adapt to change, embrace new technologies, and manage competing priorities effectively
- Experience serving as a subject matter expert, mentor, or informal leader is considered an asset
- Overtime to maintain service levels is a requirement of the role
Benefits
Comp & perks- Incentive programs and incentive compensation tied to business and individual performance
- Flexible work environment
- Health insurance
- Dental insurance
- Mental health benefits
- Vision insurance
- Short-term disability insurance
- Long-term disability insurance
- Life and AD&D insurance coverage
- Adoption/surrogacy benefits
- Wellness benefits
- Employee/family assistance plans
- Retirement savings plans
- Pension
- Global share ownership plan with employer matching contributions
- Financial education and counseling resources
- Paid holidays, vacation, personal, and sick days
- Statutory leaves of absence
- WorkSmart option