Reimbursement Case Manager

About CareMetx, LLC

CareMetx is dedicated to delivering industry-leading patient access solutions and support services. We help patients quickly start and stay on specialty therapy treatments by providing scalable, efficient digital hub services for pharmaceutical companies and healthcare providers. Our solutions streamline workflows with seamless integration for patient enrollment, consent, and prior authorization, enhancing every step of care to drive better outcomes and accelerate time-to-therapy.

Reimbursement Case Manager Position Summary

Under the general supervision of operational program leadership, the Reimbursement Case Manager is responsible for customer service and comprehensive case management. This role involves interactive work with patients, healthcare providers, pharmacies, and manufacturer clients, supporting various reimbursement and patient assistance functions. You will respond to all patient and provider account inquiries, meticulously documenting interactions into the CareMetx Connect system in full compliance with HIPAA regulations.

Primary Duties and Responsibilities

• Acts as a single point of contact and voice for all providers and patients, demonstrating compassion and serving as a patient advocate.
• Coordinates access to therapies, conducts appropriate follow-up, and facilitates access to suitable support services.
• Manages a diverse caseload based on program parameters.
• Collects and reviews all patient information to the degree authorized by program SOPs.
• Validates the completeness of all required information and provides assistance to providers and/or patients.
• Offers guidance to physician office staff and patients on how to complete and submit necessary program applications in a timely manner.
• Determines patient's eligibility and conducts patient enrollment activities, including patient assistance programs and copay assistance.
• Performs reimbursement-related activities such as benefit investigations, prior authorizations, and appeals.
• Provides exceptional customer service, resolving requests timely and accurately, and escalating complaints as needed.
• Maintains frequent phone contact with patients, provider representatives, third-party customer service representatives, and pharmacy staff.
• Provides essential reimbursement information to providers and/or patients.
• Reports all Adverse Events (AE) disclosed in alignment with training and Standard Operational Procedures (SOP).
• Coordinates with inter-departmental associates when necessary.
• Works on problems of moderate scope where analysis of data requires a review of various factors, exercising judgment within defined standard operating procedures.
• Typically receives little instruction on day-to-day work, with general instructions provided for new assignments.
• Maintains extensive knowledge of HIPAA regulations and adheres to all company policies.
• Maintains regular and reliable attendance, including being present, on time, and prepared for work as scheduled.
• Performs other related duties as assigned.

Experience and Educational Requirements

• Previous 3+ years of experience in a specialty pharmacy, medical insurance, reimbursement hub, physician’s office, healthcare setting, and/or insurance background preferred.
• Bachelor’s Degree Preferred.

Minimum Skills, Knowledge and Ability Requirements

• Excellent verbal and written communication skills.
• Ability to multi-task and adapt to changing priorities.
• Proficient keyboard skills and competency in MS Word and Excel.
• Extensive knowledge of HIPAA regulations and detailed-oriented work ethic.
• Highly organized with excellent interpersonal skills.
• Strong knowledge of pharmacy benefits and medical benefits.
• Global understanding of commercial and government payers preferred.
• Ability and initiative to work independently or as a team member.
• Demonstrated problem-solving ability and customer satisfaction focus.

Key Skills/Competency

• Case Management
• Patient Advocacy
• Reimbursement Services
• Prior Authorization
• Benefit Investigation
• HIPAA Compliance
• Customer Service
• Communication Skills
• MS Excel
• Pharmacy Benefits