Call Center RN (Remote 11AM-8PM or 12PM-9PM ET)

Brief Description

Performs as a Clinical Case Manager supporting healthcare providers and patients through telephonic support for client funded contracts. This includes telephonic support to healthcare providers, review of payor specific coverage criteria, completing clinical review of prior authorization and appeal submissions and providing written communication utilizing client approved program resources. This role will build and develop strong customer relationships and support all activities that facilitate patient access.

Specific Job Duties

• Adhere to principles as stipulated by program specific contractual agreements and company practices.
• Demonstrate clinical competency regarding reimbursement, product, and medical records and will review and train other team members on these concepts.
• Troubleshoot complex cases, identify trends (spanning multiple disease-states), investigate data, and resolve escalated issues related to complex reimbursement from both internal and external stakeholders including prior authorization denials and/or appeals.
• Perform review of payer product coverage criteria and denial letters for documentation required for submission for coverage determination.
• Provide consistent and effective communication with healthcare providers, utilizing approved resources, regarding payer coverage criteria and information that is missing for payor submission.
• Professional resource for IB/OB inquiries with focus on data collection, assembling accurate, timely, clear updates and documenting summary of follow up phone calls, patient inquiries, and outcomes including clinical notes and medical record/chart review when applicable.
• Gathers, analyzes, and prepares data for Quarterly Business Reviews (QBRs) and/or client meetings.
• Participates in program specific customer meetings and training sessions.
• Report Adverse Drug Events that have been experienced by the patient in accordance with manufacturer requirements.
• Attend manufacturer hosted conferences, customer meetings/training, and QBRs as requested (including requests to travel for in-person attendance).
• Special projects and other duties as assigned.

Scheduling & Start Date Details

This is a highly telephonic nursing role requiring continuous work within an inbound/outbound call queue along with virtual calls. Nurses must be comfortable spending the majority of their workday on the phone participating in conversations. This is a desk-based position that requires nurses to remain at their workstation throughout the workday. Calls are routed through a computer-based phone system and must be answered directly from the queue. UBC provides a desktop computer system, not a laptop. This role is designed to be performed from a dedicated home office or HIPAA-compliant workspace and is not intended for mobile or travel-based work.

Work Hours: The anticipated schedule is 11:00 AM-8:00 PM ET or 12:00 PM-9:00 PM ET and employees should expect to remain on their assigned shift based on business needs. Weekend Rotation: This role includes a rotating Saturday shift (9:00 AM – 2:00 PM ET) approximately every 5 weeks. Saturday hours are paid as overtime. Team members may also be required to work select holidays on a rotating basis to support business needs. Due to the extensive onboarding and training process, no planned time off can be accommodated during the 8-week training period.

Travel: One week of travel during training (business-paid). In addition, occasional travel may be required throughout the year for training, client meetings, conferences, team meetings, or other business-related events.

Licensing

Registered Nurse license in good standing in your state of residence; candidates must hold or be eligible to obtain a Compact Nursing License (where applicable), obtain and maintain a California RN license through endorsement upon hire, and be willing to obtain additional state licenses as required. All licensing and renewal costs are the employee's responsibility.