Operations

• Own escalations end‑to‑end: Lead resolution of complex PAs, denials, step therapy overrides, tier exceptions, continuation‑of‑therapy, and reauthorization timelines to keep treatment on schedule.
• Navigate benefits expertly: Determine the correct coverage path across medical vs. pharmacy benefits, formulary status, HCPCS/CPT coding, site‑of‑care, and specialty classification; advise partners on buy‑and‑bill vs. pharmacy fulfillment.
• Direct payer/PBM advocacy: Conduct targeted outreach to plans and PBMs to expedite decisions, correct errors, and secure patient access; prepare and submit clinical criteria summaries and appeals packets as needed.
• Clinic and provider support: Interface with clinicians and partner staff to identify missing documentation, clarify criteria, and align on next steps; coordinate with pharmacies for shipment, copay confirmation, and consent.
• Documentation and systems: Maintain precise status, outcomes, and next steps in EHR/CRM/Airtable; ensure audit‑ready records across all cases.
• Quality and mentorship: Coach other team members, perform case QA, and contribute to SOPs, checklists, and templates.
• Insights and improvement: Track payer behavior and bottlenecks, propose fixes, and partner with leadership on process and tooling improvements.

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Operations & Scheduling Coordinator – Residential Services