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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in case management, including prior authorization and appeals processing, while effectively advocating for patients and coordinating with healthcare providers. Proficient in quality assurance and process improvement initiatives within pharmacy benefit management and patient support services.
Highest-signal resume keywords
Prior Authorization ProcessingPharmacy Benefit ManagementPatient AdvocacyMedical Benefit VerificationCritical Thinking
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Case ManagementQuality ChecksMedical TerminologyClaims ProcessingProcess ImprovementData ReportingTroubleshootingMulti-tasking
Soft Skills
Excellent CommunicationMentoringCollaboration
Tools & Technologies
Microsoft Office
Certifications & Qualifications
Bachelor’s DegreeMedical AssistantSocial WorkerSenior Reimbursement Specialist
Industry Keywords
Patient Support ServicesSpecialty PharmacyHUB ServicesAdverse Drug EventsEscalation Management
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 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
- Serve as account manager for prescribers, providing case updates and resourceful information
- Interact with the client’s field team to share best practices, discuss territory trends, resolve escalations and address prescriber-related issues
- Perform quality checks on cases and report trends to leadership
- Maintain quality and production standards and comply with company, state and federal safety and environmental programs and procedures
- Troubleshoot complex cases across multiple disease states
- Report Adverse Drug Events experienced by patients in accordance with pharmaceutical requirements
- Recognize product quality complaints and forward caller/written information to a manufacturer
- Assist case managers with prior authorization and appeal requirements, process questions and escalations
- Support at-risk patients and prescribers to mitigate lapses in therapy
- Collaborate monthly with senior case managers, managers and the quality team to review quality trends and create process improvement initiatives
- Prepare and present team huddles and client presentations, with a minimum of one presentation per month
- Serve as a mentor and/or lead for other case managers
- Perform other duties as assigned
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
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