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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates clinical competency in reimbursement processes, medical records, and payer-specific coverage criteria while effectively managing telephonic support for healthcare providers and patients. Proficient in data analysis, report preparation, and maintaining strong customer relationships in a fast-paced environment.
Highest-signal resume keywords
Registered Nurse LicenseClinical Case ManagementTelephonic SupportMicrosoft Excel ProficiencyCustomer Service Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewsPrior AuthorizationData AnalysisReport PreparationTroubleshooting SkillsCritical ThinkingMedical Record ReviewPayer Coverage CriteriaDocumentation SkillsRelationship Building
Soft Skills
Strong Written CommunicationStrong Verbal CommunicationAttention to DetailTraining AbilityMultitasking
Tools & Technologies
Microsoft OfficeHIPAA-Compliant Workspace
Certifications & Qualifications
Associate DegreeProfessional Nursing LicenseCompact State License
Industry Keywords
PBMHealthcare IndustryTelehealthPatient AccessAdverse Drug Events
About the role
Key responsibilities & impact- Perform as a Clinical Case Manager supporting healthcare providers and patients through telephonic support for client-funded contracts
- Provide telephonic support to healthcare providers
- Review payer-specific coverage criteria
- Complete clinical reviews of prior authorization and appeal submissions
- Provide written communication using client-approved program resources
- Build and develop strong customer relationships and support activities facilitating patient access
- Adhere to program-specific contractual agreements and company practices
- Demonstrate clinical competency regarding reimbursement, products, and medical records
- Review and train other team members on clinical concepts
- Troubleshoot complex cases, identify disease-state trends, investigate data, and resolve escalated reimbursement issues
- Review payer product coverage criteria and denial letters for documentation needed for coverage determinations
- Communicate with healthcare providers regarding payer coverage criteria and missing submission information
- Handle inbound and outbound inquiries, collect data, provide accurate updates, and document follow-up calls, patient inquiries, outcomes, clinical notes, and medical-record/chart reviews when applicable
- Gather, analyze, and prepare data for Quarterly Business Reviews and client meetings
- Participate in program-specific customer meetings and training sessions
- Report adverse drug events according to manufacturer requirements
- Attend manufacturer conferences, customer meetings/training, and QBRs, including in-person travel when requested
- Complete special projects and other assigned duties
Requirements
What you’ll need- Minimum associate degree and professional nursing license
- Registered Nurse license in good standing in the state in which you work
- Compact State License in eligible states, or willingness to obtain it when applicable
- California RN license, or willingness to obtain it through endorsement upon hire
- Willingness to obtain additional single-state licenses upon request
- Previous experience in the PBM and/or healthcare industry
- 2+ years of experience in a customer service setting, preferably in a call center environment
- Competent ability to research, analyze, prepare reports, and document clearly
- Proficiency in Microsoft Office applications, specifically Excel
- Ability to handle a fast-paced environment and multitask
- Strong written and verbal communication skills
- Advanced problem-solving and troubleshooting skills, including critical thinking
- Strong attention to detail and relationship-building skills
- Ability to train other team members
- Comfort with continuous inbound/outbound call queue work and virtual calls
- Ability to remain at a workstation throughout the workday
- Dedicated home office or HIPAA-compliant workspace
- Availability for an assigned 11:00 AM–8:00 PM ET or 12:00 PM–9:00 PM ET shift
- Availability for rotating Saturday shifts and select holidays
- No planned time off during the 8-week training period
- Willingness to travel occasionally for training, client meetings, conferences, team meetings, or other business events
- All licensing and renewal costs are the employee's responsibility
Benefits
Comp & perks- Remote opportunities
- Competitive salaries
- Growth opportunities for promotion
- 401K with company match
- Tuition reimbursement after 90 days of employment
- 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
- Saturday hours paid as overtime
- One week of business-paid travel during training