Reimbursement Case Manager
$41,330–$68,869 year
HybridCary, North Carolina, United States
Job Summary
Conduct comprehensive benefit investigations, verify patient eligibility, and coordinate prior authorization submissions for commercial, Medicare, and Medicaid payers. Facilitate appeal coordination, financial assistance program enrollment, and claims assistance while acting as the primary liaison between patients, providers, and specialty pharmacies. Monitor authorization status, resolve coverage barriers, and maintain accurate documentation within internal systems to ensure seamless therapy access. This hybrid role in Cary, NC reports to the Supervisor of Hub Services and requires 5+ years of experience in reimbursement or patient access.
Required Qualifications
- 5+ years of related experience
- High School Diploma or equivalent
- Associate's degree preferred
- 2 years of experience in reimbursement, patient access, specialty pharmacy, healthcare operations, medical billing, physician office support, insurance verification, claims adjudication, or pharmaceutical HUB services
- Experience conducting benefit investigations and verifying medical and pharmacy benefits
- Prior authorization and appeal support experience
- Direct customer service, patient support, case management, or provider support experience
- Working knowledge of commercial, Medicare, and Medicaid benefit structures
- Experience in healthcare reimbursement, insurance verification, benefit investigations, patient access, specialty pharmacy, pharmaceutical manufacturer HUBs, medical billing, or claim adjudication
- Strong understanding of medical and pharmacy benefit structures and payer coverage requirements
- Experience supporting prior authorizations, appeals, financial assistance programs, and reimbursement processes
- Knowledge of specialty medications and the relationship between manufacturers, payers, specialty pharmacies, and healthcare providers
- Ability to manage a high-volume caseload while maintaining accuracy and attention to detail
- Excellent customer service, communication, and relationship-building skills
- Strong organizational and time management skills
- Proficiency with CRM systems (Salesforce preferred) and Microsoft Office Suite
- Strong interpersonal and communication skills
- Knowledge of commercial, Medicare, and Medicaid insurance programs
- Understanding of prior authorization processes, appeals, reimbursement methodologies, and specialty pharmacy workflows
- Familiarity with ICD-10, HCPCS, and CPT coding
- Strong analytical, problem-solving, and critical-thinking skills
- Ability to effectively prioritize and manage multiple responsibilities in a fast-paced environment
- Knowledge of HIPAA, patient privacy, and healthcare compliance requirements
- Ability to communicate complex reimbursement information in a clear and concise manner
- Ability to work independently and collaboratively across internal and external teams
- Employee will be required in office two days a week
Desired Qualifications
- Associate's degree preferred
- Working knowledge of commercial, Medicare, and Medicaid benefit structures preferred
- Familiarity with ICD-10, HCPCS, and CPT coding preferred
- Salesforce preferred
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