Reimbursement Specialist

Bayshore HealthCare; Ontario; Remote; CAD 55,000 - 85,000; Full time

Job summary

An established industry player is seeking a dedicated Reimbursement Specialist to enhance the lives of patients with respiratory diseases. This fully remote position allows you to make a significant impact by providing crucial support in navigating drug coverage options. You will advocate for patients, ensuring they receive timely access to their prescribed treatments while collaborating with healthcare professionals. If you are passionate about improving patient outcomes and thrive in a dynamic, supportive environment, this role offers an exciting opportunity to contribute to meaningful healthcare solutions.

Qualifications

• Minimum 2 years of reimbursement navigation experience in a patient program environment.
• Strong computer skills and familiarity with various software systems.

Responsibilities

• Provide drug coverage support to patients and physicians for timely access to treatments.
• Liaise with insurance providers to secure coverage for patients.

Skills

Reimbursement Navigation

Advocacy Experience

Communication Skills

Problem-Solving

Education

Experience in Patient Programs

Tools

Excel

Word

Outlook

Adobe Acrobat

Kroll

Job description

ABOUT THE ROLE
The Reimbursement Specialist will play an essential role in supporting patients living with a respiratory disease to improve both their health outcomes and quality of life. The Reimbursement Specialist will provide drug coverage support to physicians and patients, follow up on submissions pertaining to obtaining coverage through private and provincial drug plans, ensure patients have access to their prescribed treatments in a timely manner, act as a resource to physicians who are prescribing this medication, and provide continuous support for patients for renewals and coverage changes.

PLEASE NOTE: This is a fully remote role and the candidate can be based anywhere in Ontario or Quebec.

A DAY IN THE LIFE

1. Gather all pertinent and appropriate information from the chart to complete the necessary forms (private and/or provincial insurance) in a concise, organized, and professional manner.
2. Liaise and advocate with insurance providers and provincial governments as necessary to determine coverage options.
3. Keep detailed notes in the patient’s electronic chart.
4. Follow up/advocate until a decision is received to secure coverage for the patient.
5. Complete and/or review Prior Authorization (PA) or Special Authorization (SA) forms prior to submission to insurers.
6. Coordinate and gather the necessary information to ensure timely and accurate delivery of the specialty drug.
7. Coordinate and schedule patients at appropriate injection locations (home, clinic, etc.).
8. Act as a resource for program stakeholders, which include physicians, nurses, patients, clinics, and the client.
9. Assist with data integrity/rounds as required.
10. Communicate with patients regarding their third-party insurance provider, or public coverage provider, to resolve billing issues.
11. Communicate with patients’ third-party plans, or public coverage provider, to troubleshoot rejected claims.
12. Assist the pharmacist in entering prescriptions into the prescription software (Kroll), and filling/billing such prescriptions.
13. Participate in ongoing internal and/or external continuing education activities.
14. Adhere to Bayshore Policies and Procedures.
15. Participate in quality activities and continuous improvement initiatives in keeping with the company’s Quality Management System.
16. Must be able to identify and report Adverse Events to Health Canada, Med Info, and enter into source system and third-party systems.
17. Participate in proactive Health & Safety activities while performing all duties. Responsible to notify immediate supervisor of any Health & Safety risks or concerns. Responsible for completing Accident Reports for all direct reports who injure themselves on the job, within 24 hours of the incident.
18. Maintain confidentiality of client and corporate information and discuss same only with appropriate Bayshore personnel.
19. Complete other tasks, as requested.

WHAT YOU BRING TO THE TEAM

1. Minimum 2 years of Canadian public and private reimbursement navigation and advocacy experience, within a patient program environment, ideally with PA/SA drugs for chronic diseases.
2. Understanding of provincial and private coverage criteria.
3. Familiarity with the Special Authorization process for both public and private insurance.
4. Strong computer and software skills: Excel, Word, Outlook, Adobe Acrobat, CRM database entry, VOIP telephony, web portals, teleconferences, web-based meetings, Kroll and/or other pharmacy-related software systems.
5. Ease with working independently, “playing detective,” making decisions using sound judgment, and meeting deadlines.
6. Ease with working in a paperless environment.
7. Excellent written and verbal communication skills in English and in French preferred.
8. Familiarity with PIPEDA and how it applies in a confidential patient environment.