Clinical Financial Case Mgr

Scope/Position Summary
This position uses clinical knowledge for the management of the complex process of coordinating insurance verification and prior authorization of outpatient medications; provides evidence to support cutting edge therapies; provides clinical education to payers regarding current standard of care treatment. Identifies trends, and areas for needed clinical education, to decrease denials where applicable. Submission of test claims proactively supporting clinicians in efforts to identify areas where risk of denial is high to mitigate that risk. Responsibilities also include understanding and verifying benefits and obtaining prior authorization for outpatient medications. In addition, the position will at times contact patients/families in order to ascertain additional demographic, financial, and insurance information essential to the authorization processes while also informing patients of medication co-pays. Having strong clinical knowledge, utilizes the electronic medical record system to obtain pertinent medical information for prior authorization process. Solves complex customer problems. Evaluates and solves complex issues/problems; communicates and consults with the clinical team.

Minimum Qualifications
Bachelor's Degree in Nursing, Pharmaceutical Sciences or similar clinical healthcare field and 1 year experience in clinical healthcare setting or physician's practice or Bachelor's Degree in any field with 3 years experience in clinical healthcare setting or physician's practice required. Registered Nurse preferred. Experience in interpreting insurance benefit information and completing prior authorization process preferred. Knowledge of medical terminology preferred. Experience with internet and internet navigational tools is very helpful. Excellent interpersonal skills especially communication, ability to work effectively with team desired. Must be highly organized, detail oriented, and able to manage multiple projects at a time. Must complete PTCB certification within 180 days of hire, unless current PTCB certificate or other healthcare licensure is in place upon hire.