Clinical Reimbursement Manager en Inglis

Exciting Opportunity: Clinical Reimbursement Manager

Location: 2600 Belmont Ave, Philadelphia, PA 19131

Your Impact: 

Clinical Reimbursement Manager will initiate and manage the prior authorization processes for the pharmacy, resident transportation, and manage the daily operations of the medical clinic. This will include partnering with Neighborhood Clinical Leaders, Finance and Clinical Informatics to ensure all supporting documentation is complete, timely, and accurate. He/she will maintain complete, timely and accurate documentation of all approvals and denials, and transfer all clinical questions and judgment calls to the pharmacist. They also manage the supply of medications that come from specialty pharmacies.  This position must be results oriented to ensure targets are achieved and that residents receive the medications they need for optimal health. He/she should always work in a manner consistent with Inglis Values and Standards of Excellence.  To be successful, he/she must be mature, service-oriented, an excellent team member and able to manage multiple priorities with shifting agendas.  It is essential that all duties be performed with the highest level of integrity, supports Inglis Values, Standards of Excellence, and ensure compliance with regulatory agencies.  

This job description is intended to describe the general nature and level of work being performed by the person assigned to this position. The primary duties and responsibilities are intended to describe those functions that are essential to the performance of this job. This job description does not state or imply that the above are the only duties and responsibilities assigned to this position. There are other duties and responsibilities that are considered incidental or secondary to the overall purpose of this job. Employees holding this position will be required to perform other job-related duties as requested by management. All requirements are subject to possible modification to accommodate individuals with a disability.

What We're Looking For: 

·  Manages all aspects of specialty medication processing, including prior authorization (PA), ordering, tracking, and reimbursement.

·  Reviews weekly reports on PAs, appeals, and denials to ensure timely follow-up and resolution.

·       Demonstrates comprehensive understanding of proper documentation practices and standards.

·       Ensures that all supporting documentation required for billing and reimbursement is completed timely and accurately.

·       Coordinates timely completion of necessary medical consults to support the reimbursement and PA process.

·       Performs ongoing monitoring of pending documents and ensures timely submission for reimbursement and PA.

·       Investigates, verifies, and resolves any missing or incomplete information critical to the reimbursement and PA process.

·       Reports missing documentation to the appropriate department supervisor and provides education and follow-up when necessary.

·       Ensures correct documentation language and coding are used for denials, deferrals, and medication modifications.

·       Initiates insurance claim investigations and appeals as needed.

Education & Experience:

Bachelor’s degree preferred 

      LPN with at least five years’ experience in a long-term care facility. 

     Compounding pharmacy experience preferred      

     Able to maintain confidentiality in compliance with Federal HIPAA Regulation

     Experience working with Insurance carriers and PBMs (Plan Benefits Managers)

     Experienced in billing insurance claims and in the re-billing of rejected third party claims.

Pay Rate for this Role: $78k-$102k/ annually

Join Us: 

This is your chance to be a part of a team of dedicated staff (including individuals with disabilities). Be part of a team that's not just making a difference but leading the way daily. If you're ready to make a significant impact and lead with passion, we'd love to hear from you. 

Apply Now to Become a Part of the Inglis Family!