FREE ACCESS
5,000–10,000 jobs/day
See all jobs on Scoutfield
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
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 training team members to enhance customer relationships and support patient access.
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 ReviewPrior AuthorizationData AnalysisReport PreparationTroubleshootingCritical ThinkingMedical Record ReviewPayer Coverage CriteriaDocumentationRelationship Building
Soft Skills
Strong Communication SkillsAttention to DetailMultitasking AbilityTraining SkillsProblem-Solving Skills
Certifications & Qualifications
Associate DegreeProfessional Nursing LicenseCompact State License
Industry Keywords
Healthcare IndustryPBMTelehealthPatient 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 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 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 required for coverage determinations
- Communicate with healthcare providers regarding payer coverage criteria and missing submission information
- Handle inbound and outbound inquiries, collect data, document follow-up calls, patient inquiries, outcomes, clinical notes, and medical-record/chart reviews
- Gather, analyze, and prepare data for Quarterly Business Reviews and client meetings
- Participate in customer meetings and training sessions
- Report adverse drug events according to manufacturer requirements
- Attend manufacturer conferences, customer meetings, training, and Quarterly Business Reviews, including in-person events 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, where applicable, or willingness to obtain one when eligible
- California RN license through endorsement upon hire and willingness to obtain additional state licenses as required
- Previous experience in the PBM and/or healthcare industry
- 2+ years’ experience in a customer service setting, preferably in a call center environment
- Competent ability to research, analyze, prepare reports, and document clearly
- Proficient 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
- Availability for 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
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