Senior Clinical Financial Case Manager, Pharmacy Denial Management
Location
United States
Posted
9 days ago
Salary
Not specified
Bachelor Degree6 yrs expEnglish
Job Description
• Managing complex pharmacy-related medication denials across the health system
• Conducting comprehensive clinical reviews
• Submitting and tracking appeals
• Ensuring timely resolution in alignment with payer guidelines
• Serving as a liaison between the pharmacy department and third-party payors
• Advocating for optimal reimbursement and resolving technical denials
• Leading process improvement initiatives
• Mentoring staff
• Collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity
Job Requirements
- Minimum 6 years’ experience or relevant healthcare experience required
- Bachelor’s degree required
- Advanced degree in healthcare or similar field preferred
- Experience in finance, insurance, insurance appeals, medication and medical terminology desired
- Ability to communicate clearly with others and experience with Microsoft Office, electronic medical records, and intranet/internet navigation tools
- Must be highly organized, detail oriented, and able to manage multiple projects at a time
- Advanced knowledge of Medicare and commercial insurance reimbursement expected along with strong knowledge of ICD-10 codes
- Knowledge in drug billing/coding and reimbursement desired
- Excellent verbal and written communication skills desired
- Advanced competency in the use of computer-based research and medical record documentation desired
Benefits
- Medical, dental and vision insurance
- Tuition assistance for employees and their dependents
- State or alternative retirement options with competitive employer contributions
