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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in pharmacy benefit management and patient support services, with strong capabilities in prior authorization and appeals processing. Proficient in quality assurance, stakeholder communication, and process improvement initiatives.
Highest-signal resume keywords
Pharmacy Benefit ManagementPrior Authorization ProcessingPatient Support ServicesQuality AssuranceMicrosoft Office 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
Medical Benefit VerificationClaims Processing TerminologyProcess Improvement InitiativesData AnalysisCritical Thinking
Soft Skills
Excellent Written CommunicationExcellent Verbal CommunicationMulti-taskingMentoring
Certifications & Qualifications
Medical AssistantSocial WorkerSenior Reimbursement Specialist
Industry Keywords
Patient AdvocacyHealthcare ProvidersField Reimbursement RepresentativesAdverse Drug EventsProduct Quality Complaints
About the role
Key responsibilities & impact- Provide day-to-day oversight and coordination of assigned caseload
- Ensure case elements and tasks are completed timely and cases move through the process as required
- Act as the single point of contact for prior authorization and appeal processing communications
- Support patients, healthcare providers, field reimbursement representatives and other external stakeholders
- Serve as a patient advocate and resource while coordinating additional patient access services within program guidelines
- Perform quality checks on cases and report trends to leadership
- Troubleshoot complex cases spanning multiple disease states
- Interface with internal and external stakeholders to ensure optimal start to therapy
- Act as a point of contact for case managers regarding prior authorization and appeal requirements
- Provide guidance, answer process questions and address escalated issues
- Support at-risk patients and prescribers to mitigate lapses in therapy
- Collaborate with senior case managers, managers and the quality team on monthly quality-trend reviews
- Create process improvement initiatives
- Prepare and present team huddles and client presentations, with a minimum of one presentation per month
- Serve as an account manager for prescribers when needed
- Partner with client field teams on best practices, territory trends and escalations
- Analyze process quality and efficiency data
- Mentor and/or lead other case managers
- Ensure operations run smoothly and work in progress meets acceptable standards
- Perform other assigned duties
Requirements
What you’ll need- Bachelor’s degree or six years of relevant working experience
- Five (5) or more years of relevant experience in pharmacy benefit management, specialty pharmacy or patient support/access (HUB) services preferred
- Three (3) or more years of relevant experience in pharmacy and/or medical benefit verifications, prior authorization and/or appeals required
- Medical Assistant, Social Worker or Senior Reimbursement Specialist experience preferred
- Proficient in Microsoft Office applications
- Knowledge of medical and claims processing terminology
- Excellent written/verbal communication to include providing clear instructions
- Must possess a strong critical thinking skillset along with the ability to multi-task
- Must comply with applicable company, state and federal safety and environmental programs and procedures
- Must report Adverse Drug Events experienced by patients in accordance with pharmaceutical requirements
- Must recognize product quality complaints and forward caller/written information to a manufacturer
- Must work 11am–8pm EST
Benefits
Comp & perks- Remote opportunities
- Competitive salaries
- Growth opportunities for promotion
- 401K with company match
- Tuition reimbursement
- Flexible work environment
- 20 Days PTO (Paid Time Off)
- Paid Holidays
- Employee assistance programs
- Medical, Dental, and vision coverage
- HSA/FSA
- Telemedicine (Virtual doctor appointments)
- Wellness program
- Adoption assistance
- Short term disability
- Long term disability
- Life insurance
- Discount programs