Drug Prior Authorization Case Manager
- Canada
Competitive salary range of $43,875–$73,125 CAD, depending on location, qualifications, experience, and other job-related factors. · Full-time
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Job details
- Pay
- Competitive salary range of $43,875–$73,125 CAD, depending on location, qualifications, experience, and other job-related factors.
- Job type
- Full-time
- Experience
- 2–3 years of experience in a customer-focused environment, case management, claims, or a related field.
- Posting language
- English
- Posted
Original job description
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.
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.
Accountabilities
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
Why Apply Through Jobgether?
Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
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.
Accountabilities
- 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.
- 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.
- Competitive salary range of $43,875–$73,125 CAD, depending on location, qualifications, experience, and other job-related factors.
- Opportunity to participate in incentive programs with compensation linked to individual and business performance.
- Hybrid working arrangement with WorkSmart flexibility available.
- Comprehensive health and dental coverage, including mental health and vision benefits.
- Short- and long-term disability, life, and AD&D insurance coverage.
- Adoption, surrogacy, wellness, and employee/family assistance benefits.
- Retirement savings options, including pension and a global share ownership plan with employer matching contributions.
- Access to financial education and counseling resources.
- Generous paid time off, including holidays, vacation, personal and sick days, plus applicable statutory leaves.
- Flexible and inclusive working environment focused on employee well-being, professional development, and career growth.
- Opportunity to contribute to a global organization while developing expertise in complex claims and prior authorization management.
We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.
We appreciate your interest and wish you the best!
Why Apply Through Jobgether?
Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time.
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses and identifying potential inconsistencies or verification signals in application materials based on available information. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
More about this job
Responsibilities
Manage drug prior authorization requests and claims from intake through resolution, assessing cases against clinical guidelines, plan provisions, and approval criteria while meeting service timelines. Resolve complex and escalated cases, communicate decisions to members and stakeholders, provide subject-matter guidance, and contribute to risk management, training, and operational improvement.
Requirements
Requires post-secondary education or equivalent relevant experience, along with 2–3 years in a customer-focused, case management, claims, or related role and experience in benefits, insurance, disability management, or another regulated environment. Candidates should have strong analytical, communication, investigative, and decision-making skills, proficiency with Microsoft Office 365, attention to detail, and the ability to manage competing priorities independently and collaboratively.
Skills
- Drug Prior Authorization
- Claims Adjudication
- Case Management
- Clinical Guideline Assessment
- Risk Management
- Complex Case Investigation
- Analytical Skills
- Problem-Solving
- Decision-Making
- Customer Service
- Written and Verbal Communication
- Stakeholder Management
- Microsoft Office 365
- Confidentiality
- Negotiation
- Continuous Improvement
Benefits
- Incentive Programs
- Hybrid Work Flexibility
- Health Insurance
- Dental Insurance
- Mental Health Benefits
- Vision Benefits
- Short-Term Disability Insurance
- Long-Term Disability Insurance
- Life Insurance
- AD&D Insurance
- Adoption Benefits
- Surrogacy Benefits
- Wellness Benefits
- Employee and Family Assistance Program
- Pension
- Global Share Ownership Plan
- Employer Matching Contributions
- Financial Education and Counseling
- Paid Holidays
- Vacation
- Personal Days
- Sick Days
- Statutory Leaves
- Professional Development
Visa sponsorship
Not detected in the job text
Categories
- Healthcare
- Customer Service & Support
- Management & Leadership
- Finance & Accounting
Keywords
- Drug Prior Authorization
- Claims Management
- Claims Adjudication
- Case Management
- Clinical Guidelines
- Plan Provisions
- Approval Criteria
- Group Benefits
- Benefits Administration
- Disability Management
- Insurance
- Medical Terminology
- Dental Terminology
- Risk Management
- Escalated Claims
- Microsoft Office 365
- Digital Tools
- Service-Level Requirements
- Customer Experience
- Stakeholder Communication
- Operational Efficiency
- Quality Improvement
- Knowledge Sharing
- Training
- Confidentiality
- Financial Efficiency