Patient Care Advocate - Washington/Oregon

AffirmedRx is on a mission to improve health care outcomes by bringing clarity, integrity, and trust to pharmacy benefit management. We are committed to making pharmacy benefits easy to understand, straightforward to access and always in the best interest of employers and the lives they impact. We accomplish this by bringing total clarity to business practices, leading with clinical approaches, and utilizing state-of-the-art technology.
Join us in improving health care outcomes for all! We promise to do what’s right, always.
Position Summary:
The Patient Care Advocate serves as a trusted liaison between patients and healthcare providers, applying deep expertise in pharmacy benefits to ensure members receive the highest level of care and support. Exercising independent judgment, the PCA advocates for each patient's needs, provides education and guidance, and resolves the complexities of the pharmacy benefit so members can navigate the healthcare system with confidence. The role calls for sound decision-making, strong communication and interpersonal skills, and the ability to collaborate effectively with internal and external stakeholders to drive issues through to resolution.
What you will do:
Knowledge and Expertise:

Serve as a subject matter expert on the pharmacy and medical benefit structures of all major payer types — Medicare, Medicaid, and commercial — and apply that expertise to interpret coverage and resolve complex benefit questions

Provide authoritative guidance across the full prior authorization and appeals process for prescription medications, exercising judgment to determine the appropriate course of action for each case

Assess patient eligibility for copay and financial assistance from public, private, and non-profit sources, and determine when and how to connect patients with third-party assistance

Interpret PBM regulations, policies, and industry developments, and use that analysis to advise patients and inform decisions

Engagement and Collaboration:

Independently assess complex benefit, coverage, and authorization questions from members and providers, determine the appropriate resolution strategy, and communicate guidance through applicable channels

Own cases end to end, exercising discretion to resolve issues and escalating only when circumstances warrant

Counsel members and patients on coverage, benefits, and financial assistance options, tailoring guidance to their individual circumstances

Partner with internal and external stakeholders — members, providers, and pharmacies — and coordinate community-based resources to remove barriers to care

Analysis and Quality:

Analyze claims against benefit guidelines, identifying discrepancies and determining appropriate corrective action

Conduct benefit verification and test claims to validate coverage and inform resolution

Maintain thorough, accurate documentation of case activity and the rationale behind decisions

Evaluate quality and identify trends across interactions and documentation, and recommend process improvements

What you need:

Must reside in the state of Washington or Oregon

Bachelor's degree in a healthcare-related field (preferred) or equivalent experience

4+ years of proven experience in pharmacy benefits, managed care, or patient advocacy within a healthcare or PBM setting, including roles requiring independent judgment and decision-making

Strong knowledge of pharmacy and medical benefit structures, prior authorization and appeals, healthcare regulations, and payer/insurance processes

Excellent communication and interpersonal skills, with the ability to translate complex benefit and coverage information into clear guidance for members and providers

Strong analytical and problem-solving skills, with the ability to interpret claims and benefit information and navigate complex healthcare and payer systems

A patient-centered approach, with the empathy to support members through difficult or high-stakes situations

Proficiency with claims, benefit verification, and case management systems, and strong general computer skills

Strong organizational skills and attention to detail, with the ability to manage multiple priorities and adapt to changing demands

Ability to work both independently and collaboratively with internal and external stakeholders

Commitment to maintaining patient confidentiality and adhering to ethical and regulatory standards

A private, quiet workspace for remote work.

What you get:

To impact industry change in the pharmacy benefits management space, while delivering the highest quality patient outcomes

To work in a culture where people thrive because when OUR team thrives, OUR business thrives

Competitive compensation, including health, dental, vision and other benefits

Note:
AffirmedRx is committed to providing equal employment opportunities to all employees and applicants for employment. Remote employees are expected to maintain a professional work environment free of distractions to ensure optimal performance and collaboration.
Originally posted on Himalayas