Drug Prior Authorization Case Manager

CanadaRemoteFull-timemid

Case ManagerHealthcare Clinical

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Quick Summary

Overview

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Drug Prior Authorization Case Manager based in Canada.

Technical Tools

Case ManagerHealthcare Clinical

This role is responsible for the end-to-end management of complex drug prior authorization and claims cases.
You will independently assess requests against clinical guidelines, plan provisions, and approval criteria while ensuring accurate and timely decisions.
The position involves direct communication with members, providers, pharmacies, and internal stakeholders.
You will handle sensitive, escalated, high-value, and non-standard cases that require research, sound judgment, and detailed analysis.
As a subject matter expert, you will also support internal teams, outsource partners, training, and knowledge-sharing initiatives.
The role combines customer service, claims expertise, risk management, and continuous improvement within a collaborative and evolving environment.

Manage the intake, review, and adjudication of drug prior authorization requests, evaluating submissions against clinical guidelines, plan provisions, and established approval criteria.
Take full ownership of assigned cases from initial intake through resolution, prioritizing work according to urgency, complexity, customer impact, and service-level requirements.
Communicate authorization and claim outcomes clearly and professionally to members, healthcare providers, pharmacies, and internal stakeholders while maintaining expected turnaround times.
Investigate and resolve complex, escalated, sensitive, high-value, and non-standard claims or authorization scenarios through detailed research, analysis, and sound judgment.
Serve as a subject matter expert in prior authorization and claims adjudication, providing guidance to internal teams and external or outsourced partners.
Apply risk-management principles when assessing requests and contribute to effective resolution of escalated claims issues.
Participate in initiatives focused on operational efficiency, quality, customer experience, knowledge sharing, training, and continuous improvement.
Support broader organizational objectives related to financial efficiency, customer satisfaction, operational performance, and strategic priorities.

Requirements

~1 min read

Post-secondary education or an equivalent combination of education and relevant professional experience.
2–3 years of experience in a customer-focused environment, case management, claims, or a related field.
Previous experience in group benefits, claims management, disability management, insurance, or another regulated environment is required.
Proficiency with Microsoft Office 365 and confidence working with digital tools and systems in a professional environment.
Knowledge of benefits administration, medical and dental terminology, or claims-related practices is an asset.
Excellent written and verbal communication skills, with the ability to interact effectively with a diverse range of internal and external stakeholders.
Strong analytical, problem-solving, decision-making, and investigative skills, with the ability to assess risk and resolve challenging situations.
Strong attention to detail, sound judgment, confidentiality, and a customer-focused approach are essential.
Ability to manage multiple priorities in a fast-paced and changing environment while working independently and collaborating effectively with a team.
Strong influencing, negotiation, collaboration, and relationship-building skills, combined with adaptability and a willingness to embrace new technologies.
A continuous improvement mindset, solution-oriented approach, and experience acting as a subject matter expert, mentor, or informal leader are considered valuable.