Sr Care Manager
Reports To: Program Manager
Position Summary:
The Sr. Care Manager is responsible for following specific program workflows that include, but are not limited to, contacting insurance companies to obtain correct eligibility information, performing benefits investigations for both pharmacy and medical coverage as it pertains to a specific therapy, provide copay assistance, act as the single point of contact for the patient and provider office and following up with payors on prior authorization and/or appeal statuses.
The information contained herein is intended to be an accurate reflection of the duties and responsibilities of the individuals assigned to this position. They are not intended to be an exhaustive list of the skills and abilities required to do the job.AllCare Plus Pharmacy reserves the right to revise the job or to require that other or different tasks be performed as assigned.
Primary Responsibilities:
- Responsible for single point of contact communication with providers and patients in a designated geographical area
- Contact insurance companies to perform appropriate benefit investigation(s) and coverage eligibility for client product only – medical benefit 90%, pharmacy benefit 10%.
- If applicable, assist with the prior authorizations with specific attention to detail and accuracy with provided information.
- Assist patients with the enrollment process for manufacturer and non-profit organization copay assistance programs
- Provide courteous, friendly, professional and efficient service to internal and external customers including physicians and patients.
- Update job knowledge by participating in educational opportunities and training activities
- Work efficiently both individually and within a team to accomplish required tasks
- Maintain and improve quality results by adhering to standards and guidelines and recommending improved procedures
- Eligibility authorization and enrollment into Patient Assistance Program(s)
- Ability to verify insurance requirements to support current billing processes
- Demonstrate a firm grasp of medical billing processes communicating knowledge to internal and external customers
- Identifying and providing corrective action for medical billing reimbursement support specifically to provider offices
Required Qualifications:
- High School Diploma or equivalent, some college preferred
- Minimum two years’ experience in pharmacy, medical billing, insurance verification, and/or similar related healthcare experience; must include work with J-code and/or HCPCS
- Customer Service experience
- Healthcare experience
Preferred Qualifications:
- Experience with CPT codes, ICD-10 coding, and CMS 1500 Form submission
- Knowledge of third-party insurance, operating procedures, and billing practices
- Flexible work schedule
- Medical billing and coding certification is a plus
- Bilingual (Spanish) highly desirable
- Ability to use MS Office
Professional Competencies:
- Business Skills and Knowledge
- General Management
Demonstrate analytic and problem solving skills, and understand the impact of individual
decisions on other parts of the organization and the environment.- Quality improvement
Application of techniques that continually improve the quality of care provided, patient
safety, organizational performance, and the financial health of the organization.- Knowledge of the Health Care Environment
- Health Care Systems and Organizations
Demonstrate an understanding of how the various components of the health care
system is organized and financed, and how they interact to deliver medical and health
care.- The Patient’s Perspective
Understand the patient experience, demonstrate a commitment to patients’ rights and
responsibilities, and ensure that the organization provides a safe environment for
patients and their families.- Communication and Relationship Management
- Relationship Management
The ability to build and maintain relationships with internal as well as external
stakeholders that are anchored in trust and where decision-making is shared.- Communication Skills
Be able to utilize verbal, written and presentation skills to communicate an
organization’s mission, vision, values and priorities to diverse audiences.- Professionalism
- The ability to align personal and organizational conduct with ethical and professional standards
that include a responsibility to the patient and community, a service orientation, and a
commitment to lifelong learning and improvement.
AllCare Plus Pharmacy, Inc. is an Equal Opportunity Employer that complies with applicable state and local laws governing nondiscrimination in employment. We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, national origin, age, disability or genetics.
I have received, reviewed and fully understand the description and requirements of the position. I further understand that I am responsible for the satisfactory execution of the essential functions described.