What are the responsibilities and job description for the Clinical Financial Case Manager Senior Pharmacy Denial Management (S4) position at Inside Higher Ed?
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Department:James | Pharmacy Administration
Scope/Position Summary
The Clinical Financial Case Manager – Senior Pharmacy Denial Management is responsible for managing complex pharmacy-related medication denials across the health system. Key duties include conducting comprehensive clinical reviews, submitting and tracking appeals, and ensuring timely resolution in alignment with payer guidelines. This role serves as a liaison between the pharmacy department and third-party payors, advocating for optimal reimbursement and resolving technical denials.
The position requires expertise in navigating electronic medical records, interpreting clinical and billing data, and applying recognized clinical guidelines to support appeals. Additional responsibilities include leading process improvement initiatives, mentoring staff, and collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity.
Minimum Qualifications
Minimum 6 years’ experience or relevant healthcare experience required. Bachelor’s degree required. Advanced degree in healthcare or similar field preferred. Experience in finance, insurance, insurance appeals, medication and medical terminology desired. Ability to communicate clearly with others and experience with Microsoft Office, electronic medical records, and intranet/internet navigation tools. Must be highly organized, detail oriented, and able to manage multiple projects at a time. Advanced knowledge of Medicare and commercial insurance reimbursement expected along with strong knowledge of ICD-10 codes. Knowledge in drug billing/coding and reimbursement desired. Excellent verbal and written communication skills desired. Advanced competency in the use of computer-based research and medical record documentation desired
Additional Information
Location:Remote Location
Position Type:Regular
Scheduled Hours:40
Shift:First Shift
Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.
Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the Candidate Home section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the frequently asked questions.
The university is an equal opportunity employer, including veterans and disability.
Current Employees And Students
If you are currently employed or enrolled as a student at The Ohio State University, please log in to Workday to use the internal application process.
Welcome To The Ohio State University's Career Site. We Invite You To Apply To Positions Of Interest. In Order To Ensure Your Application Is Complete, You Must Complete The Following
- Ensure you have all necessary documents available when starting the application process. You can review the additional job description section on postings for documents that may be required.
- Prior to submitting your application, please review and update (if necessary) the information in your candidate profile as it will transfer to your application.
Department:James | Pharmacy Administration
Scope/Position Summary
The Clinical Financial Case Manager – Senior Pharmacy Denial Management is responsible for managing complex pharmacy-related medication denials across the health system. Key duties include conducting comprehensive clinical reviews, submitting and tracking appeals, and ensuring timely resolution in alignment with payer guidelines. This role serves as a liaison between the pharmacy department and third-party payors, advocating for optimal reimbursement and resolving technical denials.
The position requires expertise in navigating electronic medical records, interpreting clinical and billing data, and applying recognized clinical guidelines to support appeals. Additional responsibilities include leading process improvement initiatives, mentoring staff, and collaborating with providers, payors, and internal teams to enhance patient access and protect pharmacy revenue integrity.
Minimum Qualifications
Minimum 6 years’ experience or relevant healthcare experience required. Bachelor’s degree required. Advanced degree in healthcare or similar field preferred. Experience in finance, insurance, insurance appeals, medication and medical terminology desired. Ability to communicate clearly with others and experience with Microsoft Office, electronic medical records, and intranet/internet navigation tools. Must be highly organized, detail oriented, and able to manage multiple projects at a time. Advanced knowledge of Medicare and commercial insurance reimbursement expected along with strong knowledge of ICD-10 codes. Knowledge in drug billing/coding and reimbursement desired. Excellent verbal and written communication skills desired. Advanced competency in the use of computer-based research and medical record documentation desired
Additional Information
Location:Remote Location
Position Type:Regular
Scheduled Hours:40
Shift:First Shift
Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.
Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the Candidate Home section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the frequently asked questions.
The university is an equal opportunity employer, including veterans and disability.