Clinical Financial Case Management Specialist 4

Scope of Position

The Medication Access Lead position is responsible for providing efficient and efficacious care to members of and patients served by the James Medication Access team. Serving as a point of contact for the medication access team and clinical staff, including completing prior authorizations, coordination of all medication access needs, and effectively communicating within the medication access teams, clinic team and patient. This position requires clinical understanding and an expert level of payor requirement knowledge, and the ability to use and work with high proficiency in the Integrated Health Information Systems (IHIS). In addition, this position provides communication and collaboration with other departments such as Financial Counseling, MIM, PCRMs, physicians and other providers. The individual must act as a subject matter expert for the medication access team, recognizing trends and recommending process improvements to enhance workflow efficiency, while fostering collaboration and coordination with prior authorization and medication assistance teams to ensure patients have access to the medications they need.

Position Summary

This position is responsible for all work related to Clinical Finance Case Managers I-III and escalation of issues to the appropriate teams to ensure timely resolution. The Medication Access Lead requires a strong understanding of disease implications, use of various treatment modalities, expected outcomes, insurance eligibility, and clinic specific workflows, in addition to demonstrating exceptional communication, interpersonal, and organizational skillsets.

The Medication Access Lead responsibilities include advanced knowledge and understanding of payor specific requirements and benefit verification, obtaining prior authorization(s), and collecting and interpreting patient clinical information. In addition, the Medication Access Lead ensures comprehensive care of patients medication needs through accurate and timely authorization processes and when needed, contacting patients to gather pertinent information as needed. Excellent communication, verbal and written, with physicians, nurses, payers, supporting staff, and other customer groups is required to ensure accurate and visible resolutions across teams. Medication Access Leads must be able to navigate IHIS to obtain and interpret pertinent medical information for the prior authorization process, including the determination of whether a medication is being used within or outside FDA labeling, relevant lab results and any other pertinent information needed.

Minimum Qualifications

Bachelor's degree or equivalent experience. Advanced degree in relevant field may be desirable. 6 years of relevant experience required. 8-12 years of relevant experience preferred.