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Job Description
The Case Manager's primary responsibility is to support individuals with chronic illnesses by evaluating their needs, treatment plans, and overall well-being. This role involves collaborating with healthcare providers, insurers, and internal stakeholders to ensure coordinated care and timely access to prescribed therapies. Case Managers play a critical role in resolving access barriers, navigating coverage issues, and proactively preventing treatment delays. They advocate for patients throughout their care journey and may also support benefit investigations when needed.

Key Responsibilities

• Lead the care coordination process within a designated territory, balancing patient and physician needs with program requirements.
• Establish and maintain strong working relationships with healthcare providers, insurers, pharmacies, advocacy groups, and internal teams to ensure seamless care delivery.
• Assess provider needs and implement action plans to prevent delays in therapy initiation or continuation.
• Manage and maintain accurate case records, including insurance information, coverage status, and interactions with patients and providers.
• Stay current on insurance reimbursement procedures, financial assistance options, payer policies, and alternative coverage resources.
• Assist with obtaining prior authorizations, managing appeals, and supporting access to co-pay assistance and patient assistance programs.
• Educate patients and providers on insurance processes, available support services, and relevant product or disease information.
• Demonstrate leadership by taking accountability for action plan execution, supporting special projects, and driving positive outcomes for patients.
• Recommend and implement process improvements to increase efficiency and effectiveness.
• Mentor or guide team members through training, consultation, and sharing best practices on complex cases.

Qualifications

• Bachelor's degree in Healthcare, Social Work, Nursing, or a related field (or equivalent experience) preferred.
• At least 3 years of recent experience in case management or a similar healthcare support role preferred.
• Familiarity with home care coordination, utilization review, insurance reimbursement, or social services strongly preferred.
• Solid understanding of health insurance benefits, regulations, and patient support programs.
• Strong computer skills and experience with data entry and case management systems.
• Excellent communication, mediation, and problem-solving skills; bilingual (especially Spanish) is a plus.
• Ability to handle sensitive issues with professionalism and discretion.
• Demonstrated ability to work independently, manage multiple tasks, and prioritize effectively.
• Proven leadership in care coordination with a commitment to patient advocacy and operational excellence.

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