Case Manager – Drug Prior Authorization
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JobgetherDrug prior authorization
Based in CanadaFull-TimeManager
SalaryIndicative annual salary range of CAD $43,875–$73,125, depending on location, qualifications, skills, experience, and role requirements. Eligibility for incentive programs and performance-based compensation tied to individual and organizational results.
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Job Details
- Experience
- 2–3 years of experience in a customer service, case management, claims processing, or related environment.
- Required Skills
- Customer serviceQuality Assurance
Requirements
- Have postsecondary education or an equivalent combination of relevant education and experience.
- Have 2–3 years of experience in customer service, case management, claims processing, or a related environment.
- Have experience in group benefits, claims administration, disability, insurance, or another regulated environment.
- Have knowledge of benefits plan administration and medical and dental terminology or claims processes.
- Be proficient with Microsoft Office 365 applications.
- Have experience analyzing complex cases, assessing risk, and resolving sensitive or challenging situations.
- Demonstrate strong written and verbal communication, analytical, problem-solving, decision-making, and professional judgment skills.
- Be able to manage multiple priorities in a changing environment and work independently while collaborating with a multidisciplinary team.
- Demonstrate attention to detail, accuracy, confidentiality, customer focus, and the ability to build professional stakeholder relationships.
- Demonstrate influencing, negotiation, collaboration, and adaptability skills.
- A proactive approach to continuous improvement, operational excellence, and solution finding is expected.
- Experience as a subject matter expert, mentor, or informal team leader is an asset.
Responsibilities
- Receive, analyze, and adjudicate drug prior authorization requests against clinical guidelines, plan provisions, and approval criteria.
- Manage cases from initial receipt through resolution, prioritizing work by urgency and complexity.
- Investigate complex, non-standard, or escalated cases and research appropriate actions.
- Review high-value claims and cases requiring additional analysis or specialized attention.
- Communicate claims decisions to plan participants, healthcare providers, pharmacies, and internal stakeholders within service standards and processing timelines.
- Provide subject matter expertise and guidance on prior authorization and claims adjudication to internal teams and outsourced partners.
- Apply risk-management principles and professional judgment when evaluating requests and resolving cases.
- Participate in initiatives to improve operational efficiency, quality, processes, and customer experience.
- Contribute to quality assurance, training, mentoring, knowledge sharing, and continuous improvement.
- Maintain accurate case documentation and protect confidential customer and organizational information.
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