Case Manager

This is a contract position with an estimated end date in March 2028. JOB SUMMARY To 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. 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 member’s 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. This is a contract position with an estimated end date in March 2028. JOB SUMMARY To 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. 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 member’s 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. QUALIFICATIONS Education • Secondary School Diploma. Experience • 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. • Bilingual English/French will be considered an asset. QUALIFICATIONS Education • Secondary School Diploma. Experience • 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. • Bilingual English/French will be considered an asset.

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