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  • Case Manager - Pittsburgh - ConnectiveRx

    ConnectiveRx
    ConnectiveRx Pittsburgh

    4 weeks ago

    Default job background
    Description

    Overview

    The Case Manager is responsible for assisting customers with chronic illnesses in their assigned territory by addressing their well-being needs, journey, and treatment plan. This involves collaborating and maintaining consistent communication with internal and external partners to formulate, affect, and interpret operational practices to achieve resolution based on last-stop coordination concerns.

    The Case Manager utilizes care coordination to address patient and physician concerns, obtains insurance approval for designated therapy, and develops proactive plans to avoid potential delays in coverage. They facilitate the case management process along the healthcare continuum, advocating for patients' positive journeys.

    Responsibilities

    • Takes the lead in managing the Care Coordination process within an assigned territory, balancing patient and physician needs with business realities and necessities of the program.
    • Establishes and maintains professional relationships with internal and external customers while multitasking to coordinate, evaluate, and advocate for options and services to meet clients' needs.
    • Assesses physicians' needs and develops action plans to proactively mitigate delays in therapy, coordinates exchanging patient-related information with internal and external customers, and effectively manages the database.
    • Keeps up-to-date with reimbursement processes, billing/coding nuances, insurance plans, payer trends, financial assistance programs, charitable access, related resources, regional levels, and alternative resources.
    • Assists in obtaining insurance approvals/denials and/or appeals for therapy, assists patients and HCPs with processing Copay Assistance/Reimbursement and Patient Assistance Programs applications, and helps with ordering/triaging prescriptions for patients or HCPs.
    • Provides education to patients and health care providers regarding insurance requirements, options, and limitations necessary to initiate therapy, as well as relevant disease/product information.
    • Exhibits a leadership role by demonstrating accountability for action plan execution and drives for success and results, supporting special projects as requested.
    • Identifies and recommends process improvements to support operational efficiencies, effectively shares knowledge with other team members through orientation training, case studies, and consultation for complex cases.

    Qualifications

    • Bachelor's Degree (or equivalent) in a related area focusing on Health Care, Social Work, or Nursing, preferred.
    • Minimum 3 years of recent experience in the case management process, preferably with proven ability to assess ethics and legality of patients' care.
    • Experience in home care management, case management review, utilization review, social service support, insurance reimbursement, and patient advocacy, preferred.
    • In-depth understanding of health care insurance benefits, relevant state and federal laws, and insurance regulations, highly desired.
    • Experience with data entry/computer literate skills preferred.
    • Exhibits a high level of case management expertise and demonstrated leadership skills, strong verbal and written communication skills, including effective communication with clients/providers/patients and employees professionally and courteously.
    • Must possess the core values of Passion, Innovation, Integrity, and Accountability.

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