Purpose: The Reimbursement Case Manager (RCM) is a professional client‑facing role responsible for various functions, including accurate and timely response to client inquiries regarding referral status or escalation. The RCM serves as a primary point of contact for payers and manages the benefits investigation process to determine patient eligibility and coverage per plan, along with prior authorization and appeal support. The RCM interacts indirectly with external clients such as manufacturers and specialty pharmacies as well as internal teams including Operations and Program Management.
Responsibilities
Serve as primary point of contact for client and customer reimbursement inquiries and escalations.
Coordinate investigation and determination of patient benefits with internal program operations, insurance plans, and specialty pharmacy liaisons.
Review forms for completeness and communicate missing information to complete the benefit verification process.
Apply defined business rules to qualify patients for manufacturer supported programs.
Work independently to complete assigned work in accordance with SOPs and defined service levels to provide benefits verification, prescription coverage, authorization, appeal support, and answer reimbursement inquiries.
Use high‑level problem‑solving skills to research cases and resolve independently with creativity, innovation and professional judgment.
Leverage electronic and telephonic benefit investigation tools to verify eligibility, coverage, authorization and appeal process, specialty pharmacy mandates, and cost differences.
Maintain frequent phone contact with payers to gather necessary case information, insurance coverage and prior authorization or appeals processing when applicable.
Maintain clear, concise, and accurate documentation on all accounts according to SOPs.
Verify coverage and proactively enroll eligible patients into the commercial copay program.
Process patient and prescriber requests to accelerate access to therapy.
Act as an operational expert on payer trends, product access and reporting reimbursement insights and/or delays such as denials, underpayment and access delays.
Communicate frequently with program management on new insurance requirements and trends.
Provide concierge‑level service to internal and external customers; resolve requests timely and accurately; elevate appropriately.
Coordinate and collaborate with internal team members to provide reimbursement information to manufacturer representatives, HCP offices and other key personnel.
Maintain a strong compliance mindset, demonstrating clear understanding of patient privacy laws.
Participate actively in building and maintaining respectful, collaborative relationships, encouraging positivity.
Be prepared for flexible scheduling; shifts may occur between 8:00 AM and 8:00 PM EST, Monday through Friday as needed.
Other duties as assigned.
Required Qualifications
High school diploma plus 2+ years recent reimbursement experience.
Previous 2+ years of experience in a pharmacy, healthcare setting and/or pharmacy/medical insurance background.
Advanced knowledge and experience in a healthcare setting.
Experience with benefit investigation and verification of prescription benefits.
Effective oral and written communication skills focused on customer satisfaction.
Ability to independently manage caseload, prioritize work and use time‑management skills to meet deliverables.
Empathy, drive and commitment to exceptional service.
Strong analytical and organizational skills with attention to detail.
Flexible schedule ability per program business needs.
Effective oral and written communication ability.
Strong understanding of biologic/specialty pharma market and patient access challenges.
Professional expertise leverage ability.
Apply company policies and procedures to resolve challenges.
Preferred Qualifications
Undergraduate degree and/or equivalent work experience.
Certified Pharmacy Technician (CPhT).
Understanding of plan types – Government, Commercial, Medicaid, VA, Fed.
Knowledge of insurance structure (PBMs, major medical plans, co‑pay assistance/cards).
Experience with benefit investigation and prescription benefits verification.
Working knowledge of third‑party and other foundation programs.
Basic understanding of co‑pay assistance (if applicable).
Understanding of HUB patient journey, workflow, and triage (plus).
Proficiency in Microsoft Teams, Excel, Outlook and Word.
Strong analytical and organizational skills with meticulous attention to detail.
Work Environment
RareMed offers a hybrid work structure, combining remote work and in‑office requirements. Frequency of onsite requirements varies depending on role, operational needs, meetings, client visits or team collaboration activities. Employees must be within commuting distance to Pittsburgh, PA, and able to report to the office when needed. When telecommuting, employees must have reliable internet access to utilize required systems and software. The amount of time the employee is expected to work per day or pay period will not change while working from home. Employees are responsible for setting up their home office environment, including reliable internet, phone line, electricity, lighting, comfortable temperature and furniture.
Physical Demands
While performing the duties of this job, the employee is regularly required to talk or hear, frequently stand, walk, use hands and fingers, handle or feel, and reach with hands and arms.
Reasonable Accommodations
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.