Case Manager

Job Summary

To be a single point of contact offering case management support services to plan members. Act as a resource to pharmacies and patient support programs and provide continuous support for plan members on ongoing coverage, access to medications, and reimbursement navigation. This position reports to the Program Manager, Payor Solutions.

Responsibilities

• Liaise and advocate with insurance companies, patient support programs, physician offices, and other healthcare professionals to maximize reimbursement solutions.
• Encourage plan member enrollment in applicable patient support programs.
• Complete and review prior authorization forms before submission to insurers when the plan member is not enrolled in a patient support program.
• Maintain in depth knowledge of public, private, and federal funding mechanisms nationally for all program drugs.
• Maintain detailed electronic notes in the plan member’s file.
• Gather all pertinent coverage information from the plan member or patient support program to complete pharmacy referrals (private and / or public insurance, or financial assistance) in a concise, organized, and professional manner.
• Proactively offer counseling, advocacy, and assistance for plan members.
• Act as a central resource liaison for program stakeholders, including private and public insurers, pharmacies, nurses, and patient support programs.
• Adjudicate prescriptions to external payers and support Bayshore Pharmacies with troubleshooting any adjudication errors or reimbursement issues identified.
• Communicate with plan members’ third‑party plans to troubleshoot rejected claims.
• Coordinate specialty pharmacy services once funding has been secured.
• Provide updates to stakeholders as requested.
• Handle substantial telephone support as required.
• Participate in ongoing internal and / or external continuing education activities.
• Adhere to Bayshore policies and procedures.
• Participate in quality activities and continuous improvement initiatives in keeping with the company’s Quality Management System and specific performance indicators for the project.
• Participate in proactive health & safety activities while performing all duties. Notify the immediate supervisor of any health & safety risks or concerns.
• Maintain confidentiality of client and corporate information and discuss it only with appropriate Bayshore personnel.
• Complete other tasks as requested.

Qualifications

Primary Location

ON-Markham

Seniority level

Entry level

Employment type

Full-time

Job function

Other

Industries

Hospitals and Health Care

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