The Case Manager is a professional external-facing role, which is responsible for oversight of cases throughout the authorization/approval journey for patients and their providers. This role relies on critical thinking skills to drive cases through complex communication, authorization, and appeal processes, with the primary focus of expediting patients’ access to care while securing payment channels to avoid unexpected out of pocket cost. This may involve interacting with private commercial or government-run insurers, healthcare providers, suppliers/distributors, and patients to ensure access across the care continuum.

Core Duties/Responsibilities: 

• Act as a single point of contact between the internal team, client, providers, payor, facility, and patient as needed.
• Support cases through approval/denial process with a sense of urgency while maintaining accuracy.
• Provide direction to the aligned Payor Specialist Team and coordinate efforts to ensure accuracy and completeness of each case.
• Identify and share trends impacting business processes with management.  
• Prioritize and act on key client activities and follow up with customers to ensure problems are solved.
• Manage through ambiguity while designing innovative client and payor solutions.
• Make sound independent decisions in urgent and non- routine situations pertaining to client and patient scenarios.
• Interpret complex clinical documentation to prepare authorization documentation for payor submission in relation to medical policy criteria for coverage.
• Partner with the interdisciplinary team to champion their clients, patients, and customers, and is responsible for the life cycle of their case to ensure successful completion.
• Provide resources to patients, caregivers, health care providers and clients with resources available for financial assistance and transportation.
• Provide compassionate and empathetic support to patients and caregivers. 
• Coordinate with various service providers and healthcare professionals to ensure patients receive the appropriate support before and after surgery.

Skills / Requirements:

• Maintains open, effective dialogue with effective communication and is both clear and thorough in reports, documentation, and other written communications.
• High level of ability to coordinate multiple priorities and activities to accomplish goals.
• Ability to independently manage case load, prioritize work, and use time management skills to manage deliverables.
• Critical thinking and strong problem solving
• Suggests creative ideas and innovative solutions while exploring multiple alternatives and approaches to overcome obstacles and find solutions.
• Excellent follow-through with solid levels of determination and tenacity.
• Remains calm and productive during transitions or changing circumstances.
• Demonstrates composure and professionalism under difficult circumstances.
• Ability to communicate effectively both orally and in writing with a focus on customer satisfaction, with empathy, drive, and commitment to exceptional service.
• Possess a strong understanding of the US Healthcare System, public and private payer nuances, and patient access challenges for new to market, high dollar or highly complex medical interventions, products, therapies.
• Ability to leverage professional expertise and apply company policies and procedures to resolve challenges.
• Ability to develop, maintain and navigate relationships.
• Ability to interpret and understand medical documentation as it relates to each specific case and how it applies to a specific medical policy.
• Ability to be agile and adaptable in responses to rapidly changing processes and consumer needs.

Education, Certifications and Experience:

• College Degree is preferred (Bachelor's or Associate Degree).
• 4 – 6 years of experience in a healthcare setting and/or medical insurance background with a customer service focus.
• Nutrition background with Case Management experience strongly preferred.
• Experience as a Clinical Dietitian a plus.
• Experience with prior authorizations and appeals submissions desired.
• Knowledge of reimbursement processes a plus.
• Experience with maintaining detailed records of client interactions, services provided, and progress made.
• Experience in developing and/or implementing new technologies a plus.
• Experience with complex medical products and associated insurance processes a plus.

Physical Requirements: 

• As a remote-forward organization, this position operates in a professional office environment and teleworking from the employee’s home address listed in their employment file.
• Prolonged periods of sitting at a desk and working on a computer.
• Keyboarding 
• Speaking 
• Must be able to lift up to 15 pounds at times. 
• Working hours to support activities in multiple time zones. 

Our PRO-spectus Culture Philosophy

At PRO-spectus we have created a culture that is supportive, dedicated, and teamwork driven.  We celebrate each other’s joys in personal life and professional accomplishments, promoting meaningful relationships and friendships. 

Our employees bring strength of mind and spirit to make the extraordinary happen every day.  With humility and compassion at our core, PRO-spectus is proud of our relentless focus towards the higher purpose of improving the lives of patients we support.

We recognize it takes a lot of people working together with a common goal to make spectacular happen, and we never forget that at the heart of our company are the people who make it work.

PRO-spectus is an Equal Opportunity / Affirmative Action employer. All qualified individuals will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, protected veteran status, marital status or other protected status under federal, state or local laws.

At PRO-spectus, we are deeply committed to pay transparency and equity. The hourly range for this position is $40 - $54, based on experience and qualifications, with the final offer reflecting skills and other job-related factors. Beyond competitive pay, we offer a comprehensive and generous benefits package designed to support your well-being and work-life balance. 

Our benefits include robust medical, dental, and vision plans; life insurance and disability coverage; and tax-advantaged savings accounts. We also provide an Employee Assistance Program, home office benefits, and unique perks like an Employee Ownership Program. With paid time off, holidays, bereavement leave, and a 401(k)-retirement plan with employer matching, PRO-spectus prioritizes your financial and personal security. Plus, you may be eligible for a performance-based bonus opportunity. 

Join PRO-spectus, where your career growth, well-being, and contributions truly matter!