Case Manager – Drug Prior Authorization
Core
Manage complex drug prior authorization requests and claims by assessing submissions against clinical guidelines and plan provisions.
Role type
Mid-level case manager (health benefits/claims)
Builds
Adjudicated claims and prior authorization decisions for plan participants and healthcare providers
Domain
Health insurance / Group benefits
Deliverable
dashboards & analysis
Required skills
Drug prior authorization adjudication, claims administration, clinical guideline assessment, risk management, complex case investigation, stakeholder communication, Microsoft Office 365
Preferred skills
Subject matter expertise in prior authorization, mentoring, process improvement
Technologies
Microsoft Office 365
Responsibilities
Receive, analyze, and adjudicate drug prior authorization requests; manage cases from receipt through resolution; investigate complex or escalated cases; review high-value claims; communicate decisions to stakeholders; act as a subject matter expert; apply risk-management principles; contribute to quality assurance and training; support operational efficiency initiatives.
Seniority
Mid-level, hands-on IC