The Drug Prior Authorization Case Manager is accountable for the full service, end to end management of our most complex Prior Authorization claims including directly communicating with members and providers.
The Case Manager must possess the knowledge and expertise required to manage cases with total autonomy, while meeting service expectations to ensure excellent customer experience.
This role is responsible for managing all claims situations that have unique handling requirements including those that fall outside the scope of system automation and global resourcing.
Also includes the undertaking of challenging scenarios involving extensive research, sensitive/escalated issues and high dollar value claims.
The Case Manager provides direct support to a variety of stakeholders in the organization and is considered a subject matter expert who handles inquiries from various internal and external sources as well as providing peer training.
**Position Responsibilities:**
**Claims Adjudication & Prior Authorization Management (60%)**
Manage the intake, review, and adjudication of Prior Authorization drug requests, assessing submissions against clinical guidelines, plan provisions, and documented approval criteria.
Assume ownership of cases from intake through resolution, prioritizing work based on urgency and complexity.
Communicate claim outcomes to members, providers, pharmacies, and internal stakeholders while meeting service and turnaround time standards.
Conduct research and analysis to resolve complex, escalated, or non-standard claim and authorization scenarios.
**Supporting the Business (40%)**
Serve as a subject matter expert for Prior Authorization and claims adjudication, providing guidance and support to internal teams and outsource partners.
Apply risk management principles and sound judgment when assessing claim requests.
Participate in projects and initiatives that improve operational effectiveness, quality, and customer experience.
Manage escalated claims issues to achieve timely and effective resolution.
Support quality assurance, knowledge sharing, training, and continuous improvement initiatives.
**Key Shared Accountabilities:**
Commitment to Financial Efficiency and Continuous Improvement targets, as required
Commitment to improving NPS (customer) scores based on overall Operations goals
Commitment to the achievement of the divisional and organizational Strategic Priorities
**Required Qualifications:**
Post-secondary education or an equivalent combination of education and relevant experience.
2-3 years of experience in a customer-focused environment, case management, claims, or a related field.
Proficiency with Microsoft Office 365 applications.
Experience in Group Benefits, claims management, disability management, insurance, or another regulated environment.
Knowledge of benefits administration, medical and dental terminology, or claims-related practices.
**Preferred Qualifications:**
Excellent written and verbal communication skills with the ability to interact effectively with a variety of stakeholders.
Strong analytical, problem-solving, and decision-making skills.
Proven ability to manage multiple priorities in a fast-paced and evolving environment.
Strong attention to detail, sound judgment, and commitment to maintaining confidentiality.
Ability to work independently while collaborating effectively within a team environment.
Experience investigating complex cases, assessing risk, and resolving challenging situations.
Strong customer focus with the ability to build productive relationships with a wide range of stakeholders.
Strong influencing, negotiation, collaboration, and communication skills.
Ability to adapt to change, embrace new technologies, and manage competing priorities effectively.
Continuous improvement mindset with a focus on operational excellence and solution-oriented thinking.
Experience serving as a subject matter expert, mentor, or informal leader is considered an asset.
**Working Conditions:**
Work
Smart is an option for this role
Work hours aren't always “traditional” and coverage may need to align with Customer Contact Centre to provide optimal customer service
Overtime to maintain service levels is a requirement of the role
**When you join our team:**
We'll empower you to learn and grow the career you want.
We'll recognize and support you in a flexible environment where well-being and inclusion are more than just words.
As part of our global team, we'll support you in shaping the future you want to see.
**#LI-REMOTE**
The role being advertised is an existing vacancy.
**Giới thiệu về Manulife và John Hancock**
Tập đoàn Manulife Financial là nhà cung cấp dịch vụ tài chính quốc tế hàng đầu giúp mọi người quyết định dễ dàng hơn và có cuộc sống vẹn toàn hơn. Để tìm hiểu thêm về chúng tôi, hãy truy cập
https://www.manulife.com.vn/ .
**Manulife là Nhà sử dụng lao động không phân biệt đối xử**
Tại Manulife/John Hancock, chúng tôi luôn đón nhận sự đa dạng.
Chúng ta cố gắng thu hút, phát triển và duy trì lực lượng lao động đa dạng tương tự như những khách hàng mà chúng ta phục vụ, đồng thời thúc đẩy một môi trường làm việc hòa nhập, đề cao thế mạnh của từng nền văn hóa và cá nhân.
Chúng ta cam kết tuyển dụng, duy trì, thăng tiến và trả lương một cách công bằng. Đồng thời,
chúng ta quản lý tất cả các hoạt động và chương trình của mình mà không phân biệt đối xử dựa trên chủng tộc, dòng họ, xuất thân, màu da, nguồn gốc dân tộc, quyền công dân, tôn giáo hoặc tín ngưỡng tôn giáo, đức tin, giới tính (bao gồm phụ nữ mang thai và các tình trạng liên quan đến mang thai), xu hướng tính dục, đặc điểm di truyền, tình trạng cựu chiến binh, bản dạng giới, biểu hiện giới, tuổi tác, tình trạng hôn nhân, tình trạng gia đình, khuyết tật hoặc bất kỳ căn cứ nào khác được pháp luật hiện hành bảo vệ.
Ưu tiên của chúng ta là loại bỏ các rào cản để đem lại cơ hội tiếp cận việc làm bình đẳng. Đại diện Bộ phận Nhân sự sẽ làm việc với những ứng viên có yêu cầu điều chỉnh hợp lý trong quá trình ứng tuyển. Tất cả thông tin được chia sẻ trong quá trình yêu cầu điều chỉnh sẽ được lưu trữ và sử dụng tuân theo pháp luật hiện hành và chính sách của Manulife/John Hancock. Để yêu cầu điều chỉnh hợp lý trong quá trình ứng tuyển, hãy liên hệ với
[email protected] .
**Referenced Salary Location**
Waterloo, Ontario
**Working Arrangement**
Kết hợp
**Salary range is expected to be between**
$43,875.00 CAD - $73,125.00 CAD
Employees also have the opportunity to participate in incentive programs and earn incentive compensation tied to business and individual performance.
The actual salary will vary depending on local market conditions, geography and relevant job-related factors such as knowledge, skills, qualifications, experience, and education/training.
If you are applying for this role outside of the primary location, please contact
[email protected]
for the salary range for your location.
Manulife offers eligible employees a wide array of customizable advantages, including health, dental, mental health, vision, short- and long-term disability, life and AD&D; insurance coverage, adoption/surrogacy and wellness benefits, and employee/family assistance plans.
We also offer eligible employees various retirement savings plans (including pension and a global share ownership plan with employer matching contributions) and financial education and counseling resources.
Our generous paid time off program in Canada includes holidays, vacation, personal, and sick days, and we offer the full range of statutory leaves of absence.
If you are applying for this role in the U.S., please contact
[email protected]
for more information about U.S.-specific paid time off provisions.
We use data and analytics technologies, such as artificial intelligence (AI), and automated processing tools, to analyze and process the information you provide to us or third parties in the application process.
For more information, please refer to our personal information collection statement (https://careers.manulife.com/global/en/talentacquisitionprivacystatement) .
📌 Drug Prior Authorization Case Manager (Halifax Regional Municipality)
🏢 Manulife
📍 Halifax Regional Municipality