JOB SUMMARY

The Reimbursement Specialist is responsible for providing expert support to patients navigating insurance coverage for specialty medications. This role involves collaborating with Nurse Case Managers, advocating with insurers, completing authorization and appeal processes, and ensuring ongoing patient adherence. The Specialist also coordinates with pharmacies and handles issues related to drug coverage and billing, while adhering to pharmacovigilance protocols.

QUALIFICATIONS

• Completion of post-secondary education or equivalent.
• Minimum 2 years of Canadian public and private reimbursement navigation and advocacy experience, within a patient program environment is an asset.
• Understanding of provincial and private coverage criteria is an asset.
• Familiarity with PIPEDA and how it applies in a confidential patient environment.
• Understanding of provincial and private coverage criteria, Special Authorization processes and how to navigate the Canadian drug coverage landscape is an asset.
• Demonstrated expertise in delivering exceptional customer service and fostering positive relationships with internal and external stakeholders.
• Strong strategic thinking and problem-solving skills.
• Ability to multi-task, prioritize and manage time effectively.
• Ability to think under pressure.
• Excellent computer skills; Microsoft Suite of products (minimum intermediate level Excel, Word, Power Point).
• Ability to work in a quiet working environment with proven ability to work autonomously within a remote/virtual team environment.
• Established high speed internet access from home office.

• Provide exemplary courteous professional service to all program stakeholders.
• Works with Nurse Case Manager(s) to gather all pertinent and appropriate information to complete all necessary insurance forms (Private and/or Public) in a concise, organized, and professional manner.
• Represent the patient with private or public insurers to optimize drug coverage and assist with the completion of Special Authorization (SA) and/or Prior Authorization (PA) forms, when applicable.
• Liaise and advocate with insurance providers and provincial governments as necessary to determine coverage options.
• Complete insurance appeals as required.
• Follow-up and advocate until a decision is received to secure coverage for the patient.
• Coordinate with pharmacy drug coverage and dispensing. Troubleshoot any filling/billing issues as required.
• Provide ongoing support and assistance to ensure patient adherence.
• Identify, report and document Adverse Events as per Pharmacovigilance requirements.
• Participate in ongoing internal and/or external continuing education activities.
• Adhere to Bayshore Policies and Procedures.
• Participate in quality activities and continuous improvement initiatives in keeping with the company’s Quality Management System as well as key performance indicators for the program.
• Participate in proactive Health & Safety activities while performing all duties.
• Is responsible to notify immediate Supervisor of any Health & Safety risks or concerns.
• Maintain confidentiality of pharmaceutical partner(s) and corporate information and discusses same only with appropriate Bayshore personnel.
• Complete other tasks as requested.
  Qualifications: