Field Reimbursement Manager

Job Title

Primary Duties and Responsibilities

Experience and Educational Requirements

Minimum Skills, Knowledge and Ability Requirements

Physical Demands

Work Environment

Schedule

• Job Title

  CareMetx Field Reimbursement Manager

The Field Reimbursement Manager will serve as a regional expert in payer policies, handle escalated reimbursement issues, and support healthcare providers to ensure patient access to care.

Candidates with Ophthalmology and Retina experience are highly sought for this role.

• Interact with key stakeholders within healthcare provider clinics, physician practices, or hospital outpatient locations.
• Act as a liaison between healthcare provider offices and CareMetx program teams to support complex reimbursement cases.
• Take the lead on complicated or escalated reimbursement cases in assigned territory, navigating options for both patients and providers to access prescribed therapies for patients.
• Validate Prior Authorization and Appeal Requirements and communicate as needed to stakeholders.
• Track electronic payer billing codes for pharmacy and medical payers.
• Develops Appeal Package for patient support program; ensures communication occurs between stakeholders on status of Appeal, if applicable
• Covers clinics/physician's offices on patient support program and services.
• Aid program teams with handling escalated medical and pharmacy billing challenges.
• Aid with resolving reimbursement challenges.
• Provide information on relevant reimbursement topics related to our client’s products.
• Educate clinics/physician’s offices on patient support program and services.
• Communicate with patients, family, provider, manufacturer and team members.
• Resolve customer requests in a timely and accurate manner, escalates complaints accordingly.
• Aid in developing standard operating procedures regarding payer creation, payer database management and prior authorization forms library.
• Verify transactions and processes comply with organizational and departmental policies and procedures; suggest changes and solutions as appropriate.
• Independently and effectively resolves complex accounts with minimal supervision.
• Handles complex issues where analysis of situations or data requires an in-depth evaluation of variable factors.
• Networks with key contacts outside their own area of expertise.
• Acts independently to determine methods and procedures on new or special assignments.
• Exercises judgment in selecting methods, techniques and evaluation criteria for obtaining results.

Maintain regular and reliable attendance, including being present, on time, and prepared for work as scheduled.

Performs related duties as assigned.

• 5 + years’ experience working with specialty healthcare providers for both pharmacy and medical billing (including buy and bill), reimbursement, patient assistance programs, financial assistance programs, and other pharmaceutical reimbursement related activities.
• Experience in Ophthalmology, particularly Retina, is highly required. Candidates with a background supporting retina practices, anti-VEGF therapies, or ophthalmic buy-and-bill environments are strongly encouraged to apply.
• Technical knowledge of healthcare reimbursement including coding, billing, appeals process, and navigating complex reimbursement issues with both patients and providers.
• Advanced degree or specific Practice Management experience preferred

Ability to communicate effectively both orally and in writing.

Ability to build productive internal/external working relationships.

Strong interpersonal skills and attention to detail.

Ability to manage multiple tasks.

Strong analytical skills.

Excellent presentation skills

Advanced knowledge of medical insurance terminology

Strong teamwork abilities

Project management skills

Ability to work independently

Knowledge of Centers of Medicare & Medicaid Services (CMS) policies and processes, Pharmacy Benefit design and coverage policy a plus

Strong organizational skills; attention to detail.

Ability to resolve associate issues effectively and efficiently.

Ability to proficiently use Microsoft Excel, Outlook and Word.

Proven ability to appropriately escalate issues to management.

Knowledge of private payer, Medicare and Medicaid structure systems and reimbursement processes.

Understanding of patient privacy laws including HIPAA and similar state laws

Ability to travel and cover large multistate geography territories, at least 50% travel required, based on geography and territory

Ability to travel overnight

Live within 45 minutes’ drive of major airport.

Ability to schedule individual work-related travel (air, hotel, rental car as needed).

Ability to utilize own car for travel.

Technical knowledge of healthcare from a patient and provider perspective (miscellaneous codes, billing codes, appeals process).

• While performing the duties of this job, the employee is regularly required to sit.
• The employee must occasionally lift and/or move up to 10 pounds.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Must be flexible on schedule and hours

Some travel may be required