Clinical Case Manager (Wound Care)

About the role

This is a full-time remote role for Clinical Case Manager. The case manager will be responsible for verifying patient insurance coverage/benefits using online portals or calling the Payor directly for accuracy. The case manager will be required to document coverage results in our online software application, review patient clinical for payor medical necessity and initiate prior authorization or predetermination with payor. Follow up with payor and maintain communication with sales team and customer. Report out the patient benefits and authorization/predetermination results to external customers via online application or email/fax. In the case of a denial, work with the customer and payor through the appeal process. This role requires strong clinical background and understanding of standard wound care, strong computer skills to navigate through multiple software applications in a fast-paced environment, the ability to work independently, and a detail-oriented person who can provide accurate, best-in-class service to our customers. 

What you'll do

• Complete insurance benefit and coverage verifications via online portals and/or phone 

• Document benefit and coverage results in the online application 

• Initiate prior authorization and pre-determination submissions 

• Appeals support as needed 

• Communicate professionally with health insurance payers, external customers, and sales team via phone and email 

• Transcribe data from various sources into databases, ensuring data integrity and HIPAA compliance 

Qualifications

• Clinical qualifications such as RN, LPN or medical assistant 

• 2-4 years of experience is preferred 

• Understanding of health insurance plans, patient benefits, and coverage is preferred 

• Tech-savvy with the ability to adapt to system changes 

• Proficient in Excel and Adobe 

• Excellent written and verbal communication skills 

• Private home office space with high-speed internet