Manager Cvs Prior Authorization Jobs in Virginia

Position Description: 

The Reimbursement Specialist serves as a highly skilled reimbursement and patient access resource within a manufacturer-sponsored Patient Support Services (HUB) program. As an employee of the HUB services vendor, this role supports patients, healthcare providers, specialty pharmacies, and internal stakeholders by facilitating timely access to prescribed therapies through expert navigation of complex healthcare reimbursement processes. 

The Reimbursement Specialist is responsible for conducting comprehensive benefit investigations, analyzing medical and pharmacy benefit coverage, supporting prior authorization and appeal processes, identifying payer-related access barriers, coordinating with specialty pharmacy partners, and assisting healthcare providers with reimbursement-related  

requirements.
This role requires advanced knowledge of commercial and government payer environments, specialty pharmaceutical reimbursement pathways, patient access programs, and healthcare benefit structures. The Reimbursement Specialist must demonstrate the ability to independently manage complex cases, interpret payer requirements, communicate effectively with healthcare professionals, and deliver exceptional service while maintaining strict compliance with manufacturer-approved program guidelines. The successful candidate will serve as a trusted reimbursement resource within a high-performing HUB environment and will contribute to improving patient access across multiple therapeutic areas and pharmaceutical products

Key Responsibilities:  

• Comprehensive Benefit Investigation & Reimbursement Analysis 

• • Conduct detailed medical and pharmacy benefit investigations for assigned products and therapeutic area

• • Analyze patient insurance coverage including: 

• • Commercial insurance

• • Medicare Part B

• • Medicare Part D

• • Medicaid

• • Managed Medicaid

• • Employer-sponsored plans

• • Government-sponsored plans

• • Determine benefit coverage requirements, including: 

• • Deductibles 

• Prior Authorization Support & Access Navigation 

• • Review payer-specific prior authorization requirements

• • Educate provider offices regarding payer documentation expectations

• • Support completion and submission of prior authorization requests

• • Monitor authorization progress and communicate status updates

• • Identify missing information impacting approval timelines

• • Support escalation of complex access issues

• • Assist providers with understanding payer processes without influencing clinical decision-making

• Appeals & Denial Resolution Support 

• • Review payer denial information and identify appropriate next steps

• • Support healthcare providers with appeal documentation requirements

• • Coordinate collection of supporting information

• • Track appeal submissions and payer outcomes

• • Identify payer trends impacting patient access

• • Escalate recurring barriers to HUB leadership

• Specialty Pharmacy & Distribution Support 

• • Coordinate reimbursement activities with specialty pharmacy partners. 

• • Support prescription triage and fulfillment workflows. 

• • Resolve reimbursement-related delays impacting therapy initiation. 

• • Communicate coverage outcomes and access requirements. 

• • Understand specialty pharmacy network requirements and payer mandates. 

• • Assist with transitions between specialty pharmacies when required 
• Patient Assistance & Affordability Program Support  
  • Educate patients and providers regarding available manufacturer-sponsored support programs

• • Assess patient eligibility for applicable affordability program
  • Assist with documentation requirements
  • Ensure enrollment activities are completed accurately and compliantly
• Provider Education & Customer Support  
• Case Management & Documentation 

Minimum Qualifications: 

Education 

• Bachelor's degree in healthcare administration, nursing, pharmacy, life sciences, business, public health, or related field 

• In lieu of a bachelor's degree, a minimum of five (5) years of progressive experience in:  

• • Pharmaceutical HUB services 

• • Specialty pharmacy 

• • Patient access services 

• • Healthcare reimbursement 

Experience 

• Experience with three (3) years of healthcare reimbursement or patient access 

• Experience working with: 

• • Commercial payers 

• • Medicare 

• • Medicaid 

• • Specialty pharmacies 

• • Prior authorization platforms 

Required Skills:  

• Knowledge & Technical Expertise
  of: 

• • Medical and pharmacy benefit structures 

• • Specialty pharmacy workflows 

• • Prior authorization processes 

• • Appeals processes 

• • Payer policies 

• • PBM operations 

• • Specialty medication access pathways 

• • Copay assistance programs 

• • Patient assistance programs 

• • Reimbursement terminology 

• Technology Skills
  with: 

• • HUB case management platforms 

• • CRM systems 

• • Specialty pharmacy portals 

• • Electronic prior authorization systems 

• • Payer portals 

• • Microsoft Office Suite 

• • Reporting dashboards 

Applicants for employment in the US must have work authorization that does not now or in the future require sponsorship of a visa for employment authorization in the United States. 

ARM is an EEO and Affirmative Action Employer of Females/Minorities/Veterans/Individuals with Disabilities. 

All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law. 

ARM is an Equal Opportunity Employer