Nurse Case Manager, Disability Management

1 month ago

Toronto ON, Canada Bayshore HealthCare Full time

This position will be a single point of contact offering case management support services to plan members. Act as a resource to Pharmacies, and Patient Support Programs and continuous support for plan members for on‐going support with coverage, access to medications, and reimbursement navigation. This position reports into the Program Manager, Payor Solutions.
Pay rate - $57,000 to $60,000
DUTIES AND RESPONSIBILITIES
Liaise and advocate with insurance companies, Patient Support Programs, physician’ offices and healthcare professionals to maximize reimbursement solutions
Encourage plan member enrollment in the applicable Patient Support Program
Completes and/or reviews Prior Authorization forms prior to submission to insurers, when the plan member is not enrolled within a Patient Support Program
Maintain in depth knowledge of public, private, and federal funding mechanisms nationally for all program drugs.
Maintain detailed electronic notes in the plan members file
Gather all pertinent and appropriate coverage information from the plan member or Patient Support Program to complete pharmacy referrals (Private and/or Public insurance, or financial assistance) in a concise, organized, and professional manner.
Proactively offer counseling, advocacy, and assistance for plan members.
Act as a central resource liaison for program stakeholders, which include private and public insurers, pharmacies, nurses, and Patient Support Programs.
Adjudicate prescriptions to external payers and support Bayshore Pharmacies with troubleshooting any adjudication error or reimbursement issues identified.
Communicates with plan members’ third-party plans to troubleshoot rejected claims.
Coordinate specialty pharmacy services once funding has been secured
Provide updates to stakeholders as requested.
Potential for large amount of telephone support required.
Participate in ongoing internal and/or external continuing education activities.
Adhere to Bayshore Policies and Procedures.
Participate in quality activities and continuous improvement initiatives in keeping with the company's Quality Management System as well as specific performance indicators for the project.
Participate in proactive Health & Safety activities while performing all duties. Is responsible to notify immediate Supervisor of any Health & Safety risks or concerns.
Maintains confidentiality of client and corporate information and discusses same only with appropriate Bayshore personnel.
Complete other tasks as requested.
Job Qualification
.Education and/ or Experience
Secondary School Diploma.
Minimum of 2 years’ experience in customer service, in an office or pharmacy setting
Experience in the insurance, healthcare, pharmaceutical and Private/Public payers within Canada
Strong computer and technical skills: Excel, Word, Outlook
Experience in specialty pharmacy workflow with Kroll and NAV software
Professional / courteous / efficient telephone manner
Proven ability to organize time, set priorities and multi-task to meet various competing work deadlines
Candidate must have strong communication and interpersonal skills
Ability to work independently and in a team environment
Attention to detail
Excellent written and verbal communication skills
Comfort with investigating and making decisions using sound judgment
Familiarity with PIPEDA and how it applies in a confidential plan member environment.
Bilingualism, French/English is an asset.
“At Bayshore Healthcare, our commitment to Equity, Diversity & Inclusion is our strength. This is how we bring our vision of being the difference in the lives of those we care for, work with and in our communities. We have a great sense of pride in creating a culture of belonging, where individual differences are embraced and celebrated, through programs, resources and policies that support each individuals purpose, potential and wellbeing.”
Bayshore operates in accordance with the Accessibility for Ontarians with Disabilities Act, and applicable Provincial Human Rights Codes.

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