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Canada
Remote only
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Case Manager – Drug Prior Authorization based in Canada.
This role plays a key part in managing complex drug prior authorization requests and claims requiring specialized handling.
You will own cases end to end, assessing submissions against clinical guidelines, plan provisions, and established approval criteria.
You will also manage sensitive, escalated, non-standard, and high-value cases that require sound judgment and in-depth analysis.
The role involves regular communication with plan participants, healthcare providers, pharmacies, and internal stakeholders.
You will serve as a subject matter expert on prior authorization and claims adjudication, while supporting knowledge sharing and colleague training.
Your expertise will directly contribute to service quality, customer satisfaction, operational efficiency, and continuous improvement.
You will work in a dynamic, flexible, and collaborative environment that values professional development, sound decision-making, and operational excellence.
Receive, analyze, and adjudicate drug prior authorization requests according to applicable clinical guidelines, plan provisions, and approval criteria.
Manage cases from initial receipt through resolution, prioritizing work according to urgency and complexity.
Investigate complex, non-standard, or escalated cases and conduct the necessary research to determine appropriate actions.
Review high-value claims and situations requiring additional analysis or specialized attention.
Clearly communicate claims decisions to plan participants, healthcare providers, pharmacies, and internal stakeholders while meeting established service standards and processing timelines.
Act as a subject matter expert on prior authorization and claims adjudication, providing guidance and support to internal teams and outsourced partners.
Apply risk-management principles and sound professional judgment when evaluating requests and resolving cases.
Manage escalated cases and contribute to their timely, accurate, and customer-focused resolution.
Participate in projects and initiatives designed to improve operational efficiency, quality, processes, and customer experience.
Contribute to quality assurance, training, mentoring, knowledge-sharing, and continuous improvement activities.
Support objectives related to customer satisfaction, financial efficiency, and broader strategic priorities.
Maintain accurate case documentation and protect confidential customer and organizational information.
Postsecondary education or an equivalent combination of relevant education and experience.
2–3 years of experience in a customer service, case management, claims processing, or related environment.
Experience in group benefits, claims administration, disability, insurance, or another regulated environment.
Knowledge of benefits plan administration and medical and dental terminology or claims processes.
Proficiency with Microsoft Office 365 applications.
Experience analyzing complex cases, assessing risk, and resolving sensitive or challenging situations.
Excellent written and verbal communication skills, with the ability to interact effectively with a broad range of stakeholders.
Strong analytical, problem-solving, decision-making, and professional judgment skills.
Ability to manage multiple priorities in a dynamic and continuously changing environment.
Strong attention to detail and a high level of commitment to accuracy and confidentiality.
Ability to work independently while collaborating effectively with a multidisciplinary team.
Strong customer focus and the ability to build positive, professional relationships with stakeholders.
Strong influencing, negotiation, collaboration, and communication skills.
Adaptability when faced with process changes, new technologies, and competing priorities.
A proactive approach focused on continuous improvement, operational excellence, and solution finding.
Experience as a subject matter expert, mentor, or informal team leader is an asset.
Indicative annual salary range of CAD $43,875–$73,125, depending on location, qualifications, skills, experience, and role requirements.
Eligibility for incentive programs and performance-based compensation tied to individual and organizational results.
WorkSmart flexible working arrangement.
Opportunities to work from locations including Waterloo, Toronto, Kitchener, Halifax, and Montreal.
Medical and dental coverage.
Mental health and vision care coverage.
Short- and long-term disability insurance and life insurance.
Accidental death and dismemberment insurance.
Employee and family assistance programs.
Retirement savings plans, including options with employer matching contributions.
International employee share ownership program with employer contributions, subject to eligibility.
Financial education and advisory resources.
Paid time off including statutory holidays, vacation, personal days, and sick leave.
Learning, professional development, and career growth opportunities.
Flexible and inclusive work environment focused on employee well-being, collaboration, and diversity.
Opportunities to contribute to continuous improvement initiatives and projects that positively impact the customer experience.