About the Role
Title: Case Manager
Location: GU-Hagatna
Job Description:
Responsibilities
• First point of contact on inbound calls and determines needs and handles accordingly
• Creates and completes accurate applications for enrollment with a sense of urgency
• Scrutinizes forms and supporting documentation thoroughly for any missing information or new information to be added to the database
• Conducts outbound correspondence when necessary to help support the needs of the patient and/or program
• Resolve patient’s questions and any representative for the patient’s concerns regarding status of their request for assistance
• Update internal treatment plan statuses and external pharmacy treatment statuses
• Maintain accurate and detailed notations for every interaction using the appropriate database for the inquiry
• Self-audit intake activities to ensure accuracy and efficiency for the program
• Make all outbound calls to patient and/or provider to discuss any missing information and/or benefit related information
• Notify patients, physicians, practitioners, and or clinics of any financial responsibility of services provided as applicable
• Assess patient’s financial ability to afford therapy and provide hand on guidance to appropriate financial assistance
• Follow through on all benefit investigation rejections, including Prior Authorizations, Appeals, etc. All avenues to obtain coverage for the product must be fully exhausted
• Track any payer/plan issues and report any changes, updates, or trends to management
• Search insurance options and explain various programs to the patient while helping them to select the best coverage option for their situation
• Handle all escalations based upon region and ensure proper communication of the resolution within required time frame agreed upon by the client
• Serve as a liaison between client sales force and applicable party
• Mediate situations in which parties are in disagreement and facilitate a positive outcome
• Concurrently handle multiple outstanding issues and ensure all items are resolved in a timely manner to the satisfaction of all parties
• Responsible for reporting any payer issues by region with the appropriate team
• As needed conduct research associated with issues regarding the payer, physician’s office, and pharmacy to resolve issues swiftly
What is expected of you and others at this level
• Effectively applies knowledge of job and company policies and procedures to complete a variety of assignments
• In-depth knowledge in technical or specialty area
• Applies advanced skills to resolve complex problems independently
• May modify process to resolve situations
• Works independently within established procedures; may receive general guidance on new assignments
• May provide general guidance or technical assistance to less experienced team members
Qualifications
• Previous customer service experience is preferred
• High School diploma or equivalent preferred
• Patient Support Service experience, preferred
• Clear knowledge of Medicare (A, B, C, D), Medicaid & Commercial payers policies and guidelines for coverage, preferred
• Knowledge of DME, MAC practices if preferred
• Clear understanding of Medical, Supplemental, and pharmacy insurance benefit practices, preferred
• 1-2 years of Pharmacy and/or Medical Claims billing and Coding work experience
• 1-2 years experience with Prior Authorization and Appeal submissions
• Ability to work with high volume production teams with an emphasis on quality
• Intermediate to advanced computer skills and proficiency in Microsoft Office including but not limited to Word, Outlook and preferred Excel capabilities
• Previous medical experience is preferred
• Adaptable and Flexible, preferred
• Self-Motivated and Dependable, preferred
• Strong ability to problem solve, preferred
• Bilingual is preferred