Case Manager - Pittsburgh - PSKW LLC dba ConnectiveRx LLC

    PSKW LLC dba ConnectiveRx LLC
    PSKW LLC dba ConnectiveRx LLC Pittsburgh

    1 day ago

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    Description

    Job Summary

    The Case Manager plays a vital role in assisting patients with chronic illnesses in their assigned territory by gaining access to their wellbeing needs, journey and treatment plan. They collaborate and maintain consistent communications with internal and external partners (pharma reps, doctor offices or insurance companies) to formulate operational practices that achieve resolution based on last stop coordination concerns.

    Responsibilities

    • Lead the Care Coordination process within an assigned territory, balancing patient and physician needs with business realities and necessities of the program. Establish and maintain professional relationships with internal and external customers while multitasking to coordinate, evaluate and advocate for options and services to meet client needs.

    • Assess physicians' needs and develop action plans to proactively mitigate delays in therapy. Coordinate the exchange of patient-related information with internal and external customers, effectively managing database information on each individual, insurance coverage approvals, ongoing coverage requirements and all patient and provider interactions.

    • Maintain up-to-date knowledge of reimbursement processes, billing/coding nuances, insurance plans, payer trends, financial assistance programs, charitable access, related resources and regional level alternative resources.

    • Obtain insurance approvals/denials and/or appeals for therapy, assist patients and HCP with processing applications for copay assistance/reimbursement and patient assistance programs, and assist with ordering/triaging prescriptions for patients or HCP.

    • Provide education to patients and healthcare providers on insurance requirements, options and limitations necessary to initiate therapy, as well as relevant disease/product information.

    • Demonstrate leadership skills by executing action plans, driving success and results, and supporting special projects as requested.

    • Identify and recommend process improvements to support operational efficiencies, sharing knowledge with team members through orientation training, case studies and consultation for complex cases.

    • Perform other duties as assigned.

    Qualifications

    • Bachelor's degree in a related area with a focus in healthcare, social work, nursing, preferred.

    • Minimum of three years of recent experience with healthcare insurance benefits, relevant state and federal laws, and insurance regulations.

    • Proven ability to assess ethics and legality of patient care.

    • Recent experience in case management process is preferred.

    • Experience in combination of home care management, case management review, utilization review, social service support, insurance reimbursement and patient advocacy, preferred.

    • In-depth understanding of healthcare insurance benefits, relevant state and federal laws and insurance regulations, highly desired.

    • Experience with data entry/computer literate skills, preferred.

    • Exhibits high level of case management expertise and demonstrated leadership skills.

    • Strong verbal and written communication skills, including effectively communicating with clients/providers/patients and employees in a professional and courteous manner.

    • Ability to speak Spanish is a plus.

    • Ability to identify and handle sensitive issues with opposing opinions.

    • Proven ability to work independently and handle projects or multiple tasks.

    • Possesses ConnectiveRx core values of: Passion, Innovation, Integrity, Accountability.

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