Reimbursement Case Manager

CareMetx, LLC; United States; Remote; USD 52,000 - 78,000; Full time

Job summary

CareMetx, LLC is seeking a Reimbursement Case Manager to serve as the frontline contact for patients and providers, guiding enrollment and reimbursement processes. You will manage case loads, verify eligibility, and coordinate access to therapies and assistance programs while ensuring HIPAA-compliant documentation and high-quality patient service.

The role involves reviewing complex information, collaborating with pharmacies and manufacturers, and maintaining accurate records in CareMetx

Qualifications

• 3+ years of experience in a specialty pharmacy, medical insurance, or reimbursement hub.
• Bachelor’s Degree preferred.

Responsibilities

• Acts as a single point of contact for providers and patients and advocates for them.
• Coordinates access to therapies and supports services.
• Reviews patient information for completeness per SOP.
• Determines eligibility and conducts enrollment in assistance programs.
• Performs reimbursement tasks such as benefit investigations and prior authorizations.
• Provides timely, accurate responses to inquiries and escalates as needed.
• Maintains HIPAA compliance and documents interactions in CareMetx Connect.
• Collaborates with other departments as necessary.

Skills

Excellent verbal and written comms

Multitasking

MS Word & Excel

HIPAA regulations

Organized & detail oriented

Pharmacy benefits knowledge

Patient advocate

Education

Bachelor’s Degree Preferred

Job description

From intake to outcomes, CareMetx is dedicated to delivering industry-leading patient access solutions and support services that help patients quickly start and stay on specialty therapy treatments. We provide scalable, efficient digital hub services for pharmaceutical companies and healthcare providers, streamlining workflows with seamless integration for patient enrollment, consent, and prior authorization. Our best-in-class patient support services enhance every step of care, connecting patients, providers, and brands to drive better outcomes and accelerate time-to-therapy.

JOB TITLE: Reimbursement Case Manager

POSITION SUMMARY:

Under the general supervision of the operational program leadership, the Reimbursement Case Manager is responsible for customer service and case management. The Reimbursement Case Manager will work interactively with patients, healthcare providers, pharmacies, and manufacturer clients. The team will also support various reimbursement and patient assistance functions. The Reimbursement Case Manager responds to all patient, and provider account inquiries. Documents all interactions into the CareMetx Connect system in compliance with HIPAA regulations.

PRIMARY DUTIES AND RESPONSIBILITIES:

• Acts as a single point of contact and voice for all providers and patients. Works as a patient advocate and always demonstrates compassion
• Serves as a patient advocate and enhances the caller/contact experience
• Coordinates access to therapies, conducts appropriate follow up and facilitates access to appropriate support services
• Manages case load depending on the parameters of the program
• Collects and review all patient information, to the degree authorized by the SOP of the program
• Validates completeness of all required information and provides assistance to provider and/or patient
• Provide guidance to physician office staff and patients on how to complete and submit all necessary program applications in a timely manner
• Determines patient’s eligibility and conducts patient enrollment activities (example patient assistance programs and copay assistance)
• Performs reimbursement related activities such as benefit investigations, prior authorizations, appeals, etc.
• Provide exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly
• Maintain frequent phone contact with patients, provider representatives, third party customer service representatives and pharmacy staff
• Provides reimbursement information to providers and/or patients
• Reports all Adverse Events (AE) disclosed in alignment with training and Standard Operational Procedures (SOP)
• Coordinate with inter-departmental associates as necessary
• Work on problems of moderate scope where analysis of data requires a review of a variety of factors. Exercise judgment within defined standard operating procedures to determine appropriate action
• Typically receives little instruction on day-to-day work, general instructions on new assignments
• Extensive knowledge of HIPAA regulations and follows all company policies
• Maintain regular and reliable attendance, including being present, on time, and prepared for work as scheduled.
• Performs other related duties as assigned.

EXPERIENCE AND EDUCATIONAL REQUIREMENTS:

• Previous 3+ years of experience in a specialty pharmacy, medical insurance, reimbursement hub experience, physician’s office, healthcare setting, and/or insurance background preferred
• Bachelor’s Degree Preferred

MINIMUM SKILLS, KNOWLEDGE AND ABILITY REQUIREMENTS:

• Excellent verbal and written communication skills
• Ability to multi-task and adapt to changing priorities
• Competency in MS Word and Excel
• Knowledge of HIPAA regulations
• Detailed oriented and highly organized
• Excellent interpersonal skills
• Knowledge of pharmacy benefits, and medical benefits
• Global understanding of commercial and government payers preferred
• Ability and initiative to work independently or as a team member
• Ability to problem solve

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to sit
• The employee must occasionally lift and/or move up to 10 pounds.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

SCHEDULE:

• Must be flexible on schedule and hours
• Overtime may be required from time to time
• Must be willing to work weekends if required to meet company demands

CareMetx considers equivalent combinations of experience and education for most jobs. All candidates who believe they possess equivalent experience and education are encouraged to apply.

At CareMetx we work hard, we believe in what we do, and we want to be a company that does right by our employees. Our niche industry is an integral player in getting specialty products and devices to the patients who need them by managing reimbursements for those products, identifying alternative funding when insurers do not pay, and providing clinical services.

CareMetx is an equal employment opportunity employer. All qualified applicants will receive consideration for employment and will not be discriminated against based on race, color, sex, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, ancestry, or national or ethnic origin.

Artificial Intelligence in Our Recruiting and Employment Process

CareMetx uses artificial intelligence and automated decision-making technology to support parts of our recruiting, hiring, and employment process, including screening applications, scheduling interviews, and evaluating candidate qualifications. These tools support, not replace, human judgment. A qualified member of our team reviews and makes all final hiring and employment decisions.

CareMetx does not develop or use AI tools with the intent to discriminate against applicants or employees on the basis of race, color, religion, sex, age, sexual orientation, national origin, disability, veteran status, or any other protected characteristic.