Case Manager, CAPS Center Operations


Case Manager, CAPS Center Operations

Reports to:
Supervisor, Operations


The Case Manager, CAPS Center Operations is responsible for managing all patient referrals from intake through case closure, including but not limited to: benefits investigations, initiation and follow-up on prior authorizations, initiation and follow-up on all authorization denial appeals, procuring necessary documentation for the patient case, and determining financial assistance qualifications.


The Case Manager, CAPS Center Operations responsibilities include, but are not limited to the following:

  • Communications
    • Performing program welcome calls to patients
    • Performing post Benefits Investigation calls to patients and physicians explaining coverage options
    • Manage all manufacturer Sales Team inquiries unable to be determined by Power BI
    • Manage HCP inquiries as applicable
  • Case Management
    • Coordinating and assisting with prior authorizations as applicable
    • Coordinating and tracking status of payer appeals for drug coverage as applicable
    • Coordinating nurse education as needed
    • Triaging all prescriptions to the fulfillment pharmacy as applicable
    • Investigation of financial assistance availability and communication back to patient concerning next steps for action by patient
    • Specialty Pharmacy follow-up
    • Payer follow-up as applicable to facilitate benefits investigation, assistance with prior authorization and/or appeal of a denied coverage
    • Missing information follow-up with patient or HCP as applicable
    • Managing assigned cases and tasks to ensure that performance is within service levels
  • Reporting of Adverse Events/ Product Complaint received in accordance with SOP and good manufacturer practices
  • Other duties as assigned by management


Critical Skills:

The candidate must possess the following:

  • Detail oriented
  • Professional telephone etiquette
  • Basic computer knowledge
  • Ability to multitask effectively
  • Ability to recognize emotions and their effects
  • Sureness about self-worth and capabilities
  • Manage disruptive impulses
  • Maintain standards of honesty and integrity
  • Take responsibility for performance
  • Be adaptable and handle change with flexibility
  • Be innovative and open to new ideas
  • Achievement driven; constant striving to improve or to meet a standard of excellence
  • Align with the goals of the group or organization
  • Ready to take initiative and act on opportunities
  • Be optimistic and pursue goals persistently despite obstacles and setbacks
  • Be service oriented and anticipate, recognize and meet needs of others, including patients and care partners
  • Communicate clearly and send clear messages


Education and Experience:

  • Bachelor’s degree or (three) 3 years’ experience is required
  • Experience in field of social work, nursing, or medical assistance in a busy physician practice or outpatient facility is preferred
  • Insurance reimbursement/prior authorization background/experience is preferred
  • Bi-lingual in English and Spanish or Chinese/Mandarin is a plus


Physical Demands:

The candidate must possess the following abilities:

  • Ability to sit for extended periods of time
  • Ability to travel as needed


Any offer of employment is contingent on completion of a background check and drug screen to company standard.

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