Elusa Health

Position Objective: The Case Manager handles drug or treatment specific prescription processing, investigates drug or treatment specific coverage and benefits to assist the MDOs (medical doctors’ offices), as well as assists in facilitating the completion of authorizations for, or in combination with MDOs, along with handling other program related work, in order to facilitate patients’ access to treatment. The Case Manager provides customer service, operations support and is able to adapt to the changing needs of the Company’s manufacturer contracts and applicable hub services programs.

Accountability: The incumbent will report to the Program Manager.

Essential Functions:

• Manages assigned cases from end to end (from receipt of referral to triage); Included but not limited to benefit result communication, prior authorization assistance and triage to the partnered SP (Specialty Pharmacy).

• Transfers the prescription to the partnered specialty pharmacy based on triage rules.

• Contact insurance companies directly to obtain information on a patient’s specialty pharmacy benefits and/or prescription benefits in coordination with the Reimbursement Specialist.

• Contacts MDO to obtain, relay and/or verify information on patient's demographics.

• Relays pharmacy benefit coverage results for prescribed medication.

• Assists in facilitating the completion of authorizations for, or in combination with the MDO, and assists in filing an appeal if necessary.

• Connects via phone with the MDO regarding clinicals, authorizations, transfers and/or follow-ups.

• Regularly communicate with partnered manufacturer Patient Navigators to ensure alignment on patient journey or product training needs.

• Serves as primary contact for inbound calls, case notes and live chat. answers Answers inquiries regarding submitted cases, follow-ups and other case related issues, assisting the MDOs.

• Provides information regarding funding options available to patients with financial hardships.

• Assesses and relays pertinent information on patients’ pharmacy benefits to MDO and staff.

• Assists MDO with reimbursement inquiries, gathering contact information for a return call with the appropriate answer.

• Documents and make notations in the system regarding case information.

• Use discretion and independent judgment in handling customer complaints received, while documenting and forwarding to appropriate administrative staff.

• Handles and troubleshoots challenging cases for resolution and completion.

• Communicate with the Program Manager, Team Lead and other program specific team members, regarding any information received from the physician, insurance company or employees about the customer’s care or physician’s needs.

• Performs other duties as assigned by the Program Manager or the Team Lead.

• Must exhibit excellent skills in the following areas: verbal/written communication, computer/data entry/software proficiency, interpersonal and relationship-building skills, self-discipline, pro-activeness, attention to detail, and the ability to maintain strict confidentiality.

  
  

  
  

Knowledge, Skills & Abilities:

• Associate’s degree or equivalent from a two-year college, technical school or certificate program in pharmacy and/or healthcare, preferred. High School Diploma or GED, required.

• 1-3 years’ years' experience in the medical/healthcare or insurance field (i.e. hub services, pharmacy, doctor's office, hospital administration, health plan member services, etc.), required.

• Experience in pharmacy benefit investigation, retail pharmacy or specialty pharmacy adjudication strongly preferred.

• Superior level of customer service, interpersonal skills, and highly effective in working objectively with a diverse group of people.

• Excellent verbal/written communication skills, self-discipline, and attention to detail.

• Proficient in data entry, computer skills, and able to learn the department’s software system.

• Must be a team player willing to accept organizational and team goals, and function with minimal supervision.

• Maintain HIPAA patient confidentiality, as well as discretion regarding proprietary company information.

• Adaptable, able to shift gears and focus based on company and team needs.