Drug Prior Authorization Case Manager
The Drug Prior Authorization Case Manager is accountable for the full service, end to end management of our most complex Prior Authorization claims including directly communicating with members and providers. The Case Manager must possess the knowledge and expertise required to manage cases with total autonomy, while meeting service expectations to ensure excellent customer experience.
This role is responsible for managing all claims situations that have unique handling requirements including those that fall outside the scope of system automation and global resourcing. Also includes the undertaking of challenging scenarios involving extensive research, sensitive/escalated issues and high dollar value claims.
The Case Manager provides direct support to a variety of stakeholders in the organization and is considered a subject matter expert who handles inquiries from various internal and external sources as well as providing peer training.
Position Responsibilities:Claims Adjudication & Prior Authorization Management (60%)
Manage the intake, review, and adjudication of Prior Authorization drug requests, assessing submissions against clinical guidelines, plan provisions, and documented approval criteria.
Assume ownership of cases from intake through resolution, prioritizing work based on urgency and complexity.
Communicate claim outcomes to members, providers, pharmacies, and internal stakeholders while meeting service and turnaround time standards.
Conduct research and analysis to resolve complex, escalated, or non-standard claim and authorization scenarios.
Serve as a subject matter expert for Prior Authorization and claims adjudication, providing guidance and support to internal teams and outsource partners.
Apply risk management principles and sound judgment when assessing claim requests.
Participate in projects and initiatives that improve operational effectiveness, quality, and customer experience.
Manage escalated claims issues to achieve timely and effective resolution.
Support quality assurance, knowledge sharing, training, and continuous improvement initiatives.
Commitment to Financial Efficiency and Continuous Improvement targets, as required
Commitment to improving NPS (customer) scores based on overall Operations goals
Commitment to the achievement of the divisional and organizational Strategic Priorities
Post-secondary education or an equivalent combination of education and relevant experience.
2-3 years of experience in a customer-focused environment, case management, claims, or a related field.
Proficiency with Microsoft Office 365 applications.
Experience in Group Benefits, claims management, disability management, insurance, or another regulated environment.
Knowledge of benefits administration, medical and dental terminology, or claims-related practices.
Excellent written and verbal communication skills with the ability to interact effectively with a variety of stakeholders.
Strong analytical, problem-solving, and decision-making skills.
Proven ability to manage multiple priorities in a fast-paced and evolving environment.
Strong attention to detail, sound judgment, and commitment to maintaining confidentiality.
Ability to work independently while collaborating effectively within a team environment.
Experience investigating complex cases, assessing risk, and resolving challenging situations.
Strong customer focus with the ability to build productive relationships with a wide range of stakeholders.
Strong influencing, negotiation, collaboration, and communication skills.
Ability to adapt to change, embrace new technologies, and manage competing priorities effectively.
Continuous improvement…
(If this job is in fact in your jurisdiction, then you may be using a Proxy or VPN to access this site, and to progress further, you should change your connectivity to another mobile device or PC).