Senior Pharmacy Patient Advocate

				Overview:

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The Senior Pharmacy Patient Advocate serves as the primary point of contact and dedicated case owner for specialty pharmacy patients from initial enrollment through ongoing therapy adherence. Operating within a patient support services model, this role combines patient advocacy, manual and in-depth benefits verification, prior authorization management, and longitudinal care coordination to ensure patients can access, afford, and remain on their prescribed specialty therapy. The Senior Pharmacy Patient Advocate demonstrates the ability to guide patients and healthcare providers through every stage of the therapy journey, from first contact to long-term adherence, with empathy, urgency, and a strong commitment to accuracy and patient confidentiality.

Responsibilities:

KEY RESPONSIBILITIES: 

* Patient Enrollment & Onboarding

* Serve as the first point of contact for inbound patient and healthcare provider calls, accurately identifying needs and routing or resolving accordingly.
* Review, process, and complete patient enrollment applications and supporting documentation for manufacturer Patient Assistance Programs (PAP) and specialty patient support services programs with a strong sense of urgency.
* Process enrollment forms and supporting documents for missing, inconsistent, or updatable information; obtain outstanding items through outbound correspondence. Knowledge/ability to leverage internet-based tools/technology to identify missing information prior to outreaching to patients/providers to obtain.
* Pre-screen and verify patient eligibility based on PAP and other program criteria; communicate eligibility determinations to patients and authorized representatives daily.
* Verify prescription information prior to processing, including prescriber, patient demographics, medication, dose, quantity, and refill authorization.
* Notify patients, authorized representatives, healthcare providers of enrollment approvals, denials, and required next steps in a timely and professional manner.
* Assist with coordination of shipment and medication fulfillment and delivery.
* Explain program eligibility, services, and enrollment processes clearly to patients, caregivers, authorized representatives, and physician office staff.
* Prioritize workload to ensure patient enrollments are processed within program-specified timeframes.

Benefits Verification & Payer Management

* Perform comprehensive patient-level benefits verifications across commercial, Medicare (Parts A, B, C, D), Medicaid, and supplemental insurance plans.
* Assess patients' financial ability to afford therapy and provide hands-on guidance toward appropriate financial assistance programs and coverage options.
* Identify and locate prior authorization (PA) templates per payer-specific requirements; track and follow through on all outstanding PAs to ensure timely coverage.
* Identify and locate prior authorization appeal templates per payer-specific requirements and communicate requirements to healthcare providers. Track and follow through on all outstanding prior authorization appeals to ensure timely coverage.
* Track payer and plan issues by region; identify trends and report changes or systemic issues to management promptly.
* Research insurance options and explain available programs to patients, assisting them in selecting the best available coverage for their situation.

Longitudinal Case Management & Therapy Adherence

* Maintain continuous ownership of each patient case from initial enrollment through active therapy, serving as the primary liaison for all parties - patient, caregiver, prescriber, pharmacy, and payer.
* Conduct proactive outbound calls and correspondence to patients and providers to share enrollment status details and other program related details.
* Update internal case statuses and coordinate with pharmacy partners to ensure accurate, real-time therapy and shipment status.
* Provide patients with order availability, tracking, and shipping information as needed; schedule and coordinate treatment delivery to the patient or healthcare provider.
* Perform problem-solving on refill-related issues, prescription changes (dose, medication, prescriber), and insurance transitions to prevent gaps in therapy.
* Self-audit case activities regularly to identify errors, inefficiencies or adherence risks and correct proactively.

Communication & Escalation Management

* Maintain accurate, detailed notations for every patient interaction in the appropriate case management system, ensuring a complete and auditable record.
* Investigate unresolved issues at first contact and follow through to full resolution; provide first-call resolution wherever possible.
* Concurrently manage multiple open cases and outstanding items, ensuring all are resolved within program-required timeframes.
* Handle program-specific patient/provider escalations; determine mitigation strategies and communicate resolutions to all involved stakeholders.
* Respond to program inquiries from patients, authorized representatives, healthcare providers, advocates, and caregivers in a prompt, courteous, and compliant manner.

Compliance & Regulatory Responsibilities

* Maintain strict patient confidentiality in accordance with HIPAA regulations, applicable privacy standards, and all state and federal laws at all times.
* Recognize and report adverse events (AE) and product quality complaints (PQC) received during patient interactions in accordance with standard operating procedures and current Good Manufacturing Practices (cGMP).

* Follow program-specific business rules, timelines, and processing protocols; adapt quickly to changes in program requirements.
* Accurately capture and update patient data and case information in all applicable systems; apply strong attention to detail in all data entry activities.
* Prepare and maintain patient profiles, medication administration records, and related case documentation for pharmacist review where applicable.

The above duties are meant to be representative of the position and not all inclusive.

Qualifications:

* MINIMUM JOB REQUIREMENTS:

* High School diploma or equivalent required. 
* Minimum 5 years of experience in patient support services, specialty pharmacy, or a patient support hub environment. 
* Minimum 5 years of benefits verification experience across commercial, Medicare (Parts A, B, C, D), Medicaid, and supplemental insurance plans, including working knowledge of U.S. private and government payer policies. 
* Minimum 5 years of prior authorization submission, follow-up, and appeals processing. 
* Familiarity with HIPAA regulations and patient privacy standards. 
* Proven ability to manage a caseload independently, prioritize competing tasks, and meet deadlines in a high-volume environment. 
* Intermediate to advanced proficiency in Microsoft Office (Word, Excel, Outlook) and case management software systems.

PREFERRED QUALIFICATIONS:

* Associate degree or technical school training in healthcare, pharmacy, or a related field; or equivalent combination of education and experience.
* Knowledge of specialty pharmacy operations including order entry, prescription verification, pharmacy claims billing, and reimbursement processing.
* National pharmacy technician certification through PTCB or ExCPT; state pharmacy technician registration where required.
* Experience with pharmacy management platforms such as PrimeRx, CoverMyMeds, or comparable systems.
* Bilingual proficiency in English and Spanish strongly preferred.

KNOWLEDGE, SKILLS & ABILITIES:

Patient-Centered Competencies

* Demonstrated empathy, compassion, and sensitivity when communicating with patients, caregivers, and clinical staff.
* Ability to listen actively and de-escalate difficult or emotionally sensitive situations with tact and professionalism.
* Genuine passion for patient advocacy and
			

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