Priovant is committed to developing and commercializing therapies that address high unmet need in autoimmune disease. As we prepare for launch, we are building a world-class Patient Services organization to support patients, healthcare providers (HCPs), and access pathways from day one.
The Case Management (CM) role serves as a payer-facing reimbursement expert within the Priovant Patient Services internal hub, responsible for navigating complex insurance coverage, resolving access barriers, and supporting escalated cases for Priovant’s rare disease therapy. The role partners closely with internal teams, including Patient Access Liaisons (PALs) and operations, to ensure efficient case progression while maintaining a strong focus on compliance and accurate documentation.
This position plays a critical role in supporting patient access by driving solutions within complex and non-standard access scenarios.
Key Responsibilities
Payer Access Management
- Serve as the primary payer-facing access expert, managing complex insurance coverage, benefits investigations, prior authorizations, appeals, and medical exception processes.
- Analyze and interpret payer policies and formulary requirements to determine appropriate access pathways and resolve barriers, including denials and non-standard coverage scenarios.
- Support escalation management for high-complexity cases, ensuring timely resolution, accurate documentation, and appropriate access strategy execution.
Cross-Functional Collaboration & Case Strategy
- Partner closely with PALs, Market Access, Specialty Pharmacies, the Copay Vendor and internal operations teams to align on case strategy and ensure seamless execution of access and reimbursement workflows.
- Provide subject matter expertise on payer dynamics, coverage trends, and access challenges to support informed decision-making and launch readiness activities.
- Identify systemic access barriers and contribute to process improvements and business optimization efforts.
Specialty Reimbursement Execution
- Leverage deep knowledge of specialty pharmacy and payer reimbursement structures to optimize access outcomes, including copay assistance, bridge programs, and foundation support resources.
- Anticipate payer behavior and coverage changes to proactively mitigate access and reimbursement delays and support time-to-therapy goals.
Inbound Customer Service Support
- Support inbound phone coverage, general email inquiries, and web inquiries as a secondary responsibility, applying customer service skills to respond to patients, caregivers, and HCPs in a professional and compliant manner.
The Case Manager will route inquiries as needed and appropriately, and deliver a consistent, high-quality experience reflective of Priovant’s patient-first values.
Operational Excellence & Compliance
- Maintain accurate, timely, and compliant documentation of all case activity within CRM systems in accordance with SOPs and regulatory requirements.
- Track reimbursement outcomes and escalation trends to support reporting, performance insights, and continuous improvement.
- Ensure disciplined execution in a high-volume, fast-paced hub environment with strong attention to detail and accountability.
Core Competencies
1. Payer Expertise & Access and Reimbursement Knowledge
- Deep understanding of payer systems, including prior authorization, appeals, medical exceptions, and coverage policy interpretation.
- Strong knowledge of commercial, Medicare, and Medicaid reimbursement structures and specialty pharmacy dynamics.
- Ability to independently analyze complex reimbursement scenarios and determine appropriate resolution pathways within established processes.
2. Patient-Centric Access Mindset
- Demonstrates a strong understanding that reimbursement decisions directly impact patient access and time-to-therapy.
- Approaches payer problem-solving with urgency and accountability for downstream patient outcomes, even in a non–patient-facing role.
- Balances regulatory, payer, and program requirements with a consistent focus on minimizing barriers to therapy initiation and continuity of care.
3. Complex Problem Solving & Critical Thinking
- Demonstrated ability to resolve high-complexity access barriers within standard workflows and established program guidelines.
- Applies structured, analytical thinking to interpret payer requirements and identify appropriate resolution strategies.
- Balances urgency with accuracy in time-sensitive access processes.
4. Issue Identification & Escalation Judgment
- Strong ability to recognize complex or high-risk access issues and route them appropriately for leadership review.
- Exercises sound judgment in determining when cases require escalation versus standard workflow resolution.
- Ensures clear, accurate, and timely documentation to support effective downstream decision-making.
5. Cross-Functional Collaboration & Influence
- Effectively partners with internal teams (PALs, Market Access, Specialty Pharmacy, Operations) to align access and reimbursement strategy and execution.
- Communicates payer insights clearly and concisely to both technical and non-technical stakeholders.
- Influences outcomes through subject matter expertise, structured problem framing, and proactive communication.
6. Operational Discipline & Compliance
- Strong attention to detail with consistent, audit-ready documentation within CRM systems.
- Ability to manage multiple complex cases simultaneously in a high-volume environment.
- Working knowledge of HIPAA, OIG guidance, and pharmaceutical compliance standards.
7. Customer Service & Phone Communication
- Demonstrates basic customer service skills, including professional phone etiquette, active listening, and the ability to communicate clearly and empathetically with patients, caregivers, and HCPs.
- Ability to triage inbound inquiries efficiently, route calls as appropriate, and maintain a calm, solution-oriented demeanor while keeping the primary emphasis on payer expertise and reimbursement case management.
Qualifications
Minimum Qualifications
- Bachelor’s degree required.
- 3-5+ years of experience in the hub space, including benefits investigations, prior authorizations, and appeals.
- Experience supporting rare disease, specialty, or highly complex therapeutic areas preferred.
Ideal Candidate Profile
- Recognized as a payer expert with experience navigating insurance plans, coverage policies, and complex access pathways
- Deep hands-on experience managing access workflows, including BIs, PAs, appeals, medical exceptions, and specialty pharmacy coordination, with the ability to resolve complex and non-standard access scenarios
- Experience supporting complex reimbursement and patient access programs, including launch or early commercial environments
- Strong problem-solving, communication, and documentation skills, with the ability to clearly articulate reimbursement challenges and maintain compliant records within CRM systems
- Proven ability to collaborate cross-functionally with internal teams (e.g., PALs, operations, etc.) to ensure seamless case progression in a fast-paced, high-accountability environment.
- Comfort working in a fast-moving, high-accountability organization.
Compensation & Benefits
- Base Salary: $120,000 - $130,000
- Annual Bonus: 15% target
- Long-Term Incentives: Stock options, 401K with match
- Comprehensive Benefits Package