Sr. Reimbursement Case Manager

CareMetx, LLC; Kissimmee (FL); On-site; USD 65,000 - 90,000; Full time

Job summary

CareMetx is seeking a Senior Reimbursement Case Manager to support patients, providers, and payers. Under supervision, you will handle benefits investigations, prior authorization support, and call triage while ensuring HIPAA compliant documentation in the CareMetx Connect system.

You will manage a regional caseload, communicate with payors, and facilitate access to therapies. The role requires 3+ years in healthcare or insurance, a Bachelor's preferred, and strong MS Word/Excel skills.

Qualifications

• 3+ years in a physician's office, healthcare setting, or insurance background preferred.
• Bachelor’s Degree preferred.
• HIPAA knowledge.
• Excellent verbal and written communication.
• Ability to multi-task and adapt to changing priorities.

Responsibilities

• Serve as a single point of contact for providers, patients, and product team.
• Handle escalated accounts and issues.
• Coordinate access to therapies and prior authorizations.
• Document interactions in CareMetx Connect per HIPAA regulations.
• Track and follow up on prior authorizations and appeals.
• Provide exceptional customer service to internal and external customers.

Skills

Communication skills

Multitasking

Detail-oriented

Interpersonal skills

Pharmacy benefits knowledge

Payer landscape knowledge

Education

Bachelor's Degree preferred

Tools

MS Word

MS Excel

Job description

All Jobs > Sr. Reimbursement Case Manager

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:

Sr. Reimbursement Case Manager

POSITION SUMMARY:

Under the general supervision of the Supervisor and Director, the Senior Reimbursement Case Manager is responsible for customer service and case management. The Senior Reimbursement Case Manager will work interactively with patients, healthcare providers, specialty pharmacies, and manufacturer clients. The team will also support various reimbursement functions including but not limited to benefits investigations, prior authorization support and call triage. Responds to all patient, nursing, and provider account inquiries. Documents all provider, payer, and client interactions into the CareMetx Connect system in compliance with HIPAA regulations.

PRIMARY DUTIES AND RESPONSIBILITES:

• Acts as a single point of contact and voice for all providers, patients and product/sales team.
• Handles escalated accounts and issues.
• Manages special projects and tasks.
• Serves as a patient advocate and enhances the collaborative relationship between the payer, HCP and patient.
• Coordinates access to therapies, conducts appropriate follow up and facilitates access to appropriate support services.
• Manages a regional case load.
• Collect and review all patient insurance benefit information, to the degree authorized by the SOP of the program.
• Provide assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications in a timely manner.
• Track and follow up on prior authorization and appeal requests when necessary.
• 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 provider representatives, third party customer service representatives and pharmacy staff.
• Report any reimbursement trends/delays to the supervisor.
• Process any correspondence.
• Provide all necessary documentation required to expedite prior authorization requests including demographic, authorization/referrals, National Provider Identification (NPI) number and referring physicians.
• Coordinate with inter-departmental associates as necessary.
• Communicate effectively with payors to ensure accurate and timely benefit investigations.
• 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.
• Must be knowledgeable of HIPAA regulations and HIPAA compliant at all times.
• 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 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
• Extensive travel is required (30% travel)

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.