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Care Manager & Prior Authorization Specialist
As a Care Manager at Rezilient Health, you will play a critical role in supporting patients, providers, and partners throughout the care continuum. You will lead the clinical onboarding of new contracts, manage complex tasks, coordinate referrals and authorizations, and ensure seamless communication between all stakeholders. Your work will directly impact patient outcomes, operational efficiency, and the overall success of our innovative Cloud Clinic model.
At Rezilient, we’re dedicated to revolutionizing primary and specialty care by delivering convenient, timely, and seamless access to healthcare. Our innovative hybrid CloudClinic model, powered by our onsite team of Medics and virtual Providers fosters a personalized and digital healthcare experience, putting the patient at the center of their care. By leveraging cutting-edge technology, we streamline care delivery, allowing our Providers to focus on patient well-being, and we continuously expand our specialty services to provide the most comprehensive and convenient healthcare possible.
Requirements
Clinical Onboarding & Contract Support
Lead the clinical onboarding process for all new contracts, ensuring timely collection of all necessary information and effective collaboration with Operations and Customer Success teams.
Represent Rezilient Care Coordination in all onboarding meetings, serving as the primary point of contact for contract-related clinical questions.
Design, build, and maintain a comprehensive care navigation database to support all care management activities.
Ensure compliance with regulatory requirements and organizational policies during onboarding and data collection.
Care Navigation & Patient Advocacy
Coordinate and manage patient referrals, including high-priority cases, ensuring timely follow-up and resolution of health concerns.
Serve as a patient advocate by facilitating communication between patients, families, providers, and payers to optimize health outcomes.
Communicate proactively with patients to provide updates, answer questions, and accommodate preferences related to referrals, orders, and care navigation.
Identify and address barriers to care (e.g., transportation, financial, language, or health literacy challenges) and proactively support development of solutions to ensure patients receive timely, appropriate services.
Maintain organized, accurate, and detailed records of all care coordination activities in accordance with HIPAA and all applicable privacy regulations.
Care Coordination & Prior Authorizations
Lead and manage prior authorization processes, including peer-to-peer reviews, insurance rebuttal letters, single case agreements, and coordination with plan representatives.
Facilitate the retrieval and secure transfer of medical records from previous specialists, manage release of information forms, and ensure all necessary documentation is available for patient care.
Conduct comprehensive insurance benefit reviews for employer plans, documenting coverage for preventative services, behavioral health, specialty care, and pharmacy needs.
Monitor and track the status of authorizations, referrals, and orders to ensure timely completion and communication to all stakeholders.
Stakeholder & Partner Collaboration
Serve as the liaison with point solutions and cost containment partners, ensuring training, logins, and functionality are established for new launches.
Collaborate with clinical teams, providers, and external partners to coordinate patient referrals, orders, and procedures in accordance with medical plan benefits and evidence-based guidelines.
Communicate with insurance administrators and healthcare facilities to verify provider participation, coverage, pre-authorization requirements, and scheduling availability.
Build and maintain strong working relationships with internal and external stakeholders to facilitate seamless care transitions.
Process Improvement & Training
Develop and update care coordination workflows, training materials, and standard operating procedures to reflect best practices and regulatory changes.
Lead initial, ongoing, and remediation training for new care coordinators to ensure consistent, high-quality service delivery.
Assist in building and maintaining databases of preferred specialty providers for all contracts, ensuring up-to-date and accurate information.
Participate in quality improvement initiatives and contribute to the development of performance metrics for care coordination.
Technology & Systems Navigation
Efficiently navigate multiple healthcare systems, including EMRs, payer portals, billing software, patient messaging platforms, and spreadsheets.
Ensure accurate and timely documentation in all relevant systems to support care continuity and compliance.
Support the systemization and optimization of client contracts and referral processes to create a scalable and efficient care coordination operation.
Qualifications
Required:
Bachelor’s degree in healthcare administration, nursing, or related healthcare field (or equivalent experience)
Minimum 3 years of experience in care coordination, case management, or a clinical support role
Strong knowledge of insurance benefits, prior authorizations, and referral management
Excellent organizational, problem-solving, and communication skills
Demonstrated ability to manage multiple priorities in a fast-paced, evolving environment
Proficiency with EMR systems, payer portals, and standard office software
Preferred:
Experience in a startup or high-growth healthcare technology environment
Familiarity with Athena Health EMR and Google Suite applications
Medical assistant, Paramedic, Billing and Coding, or clinical background
Benefits
This opportunity offers the chance to shape the future of healthcare in a culture where your ideas and contributions have a meaningful impact on the organization's future. You’ll be part of a supportive, collaborative, and diverse team, with competitive compensation and benefits that include generous PTO, paid family leave, comprehensive medical, dental, vision, and life insurance, as well as stock options.
Raleigh, NC, USA
Negotiable Salary
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