Manager, Field Reimbursement

Position Summary

Under the general direction of Senior Operations leadership/Director the Manager of Field Reimbursement is responsible for the overall administration of the Field Reimbursement program as required by the client contract. The Manager of Field Reimbursement will also serve as a field or home-office based regional expert in payer policies, will handle escalated reimbursement issues and will provide support to healthcare providers to facilitate appropriate patient access and utilization of services to ensure their access to care. Candidates with Ophthalmology and Retina experience are highly sought for this role.

Primary Duties and Responsibilities

• Maintains open communication with the staff
• Proactively identifies program issues and proposes ways in which to address their concerns
• Ensures open communication with the staff
• Validates Prior Authorization and Appeal Requirements and communicates as needed to stakeholders
• Tracks 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
• Coordinates with patient support program representatives
• Assists program teams with handling escalated medical and pharmacy billing challenges
• Assists with resolving reimbursement challenges
• Provides information on relevant reimbursement topics related to our client’s products
• Educates clinics/physician’s offices on patient support program and services
• Effectively communicates with patients, family, provider, manufacturer and team members
• Provides exceptional customer service to internal and external customers; resolves any customer request in a timely and accurate manner and escalates complaints accordingly
• Affords assistance in developing standard operating procedures regarding payer creation, payer database management and prior authorization forms library
• Verifies transactions and processes comply with organizational and departmental policies and procedures; suggests 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

Qualifications

• 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
• Previous 2+ years supervisory experience is required
• 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
• 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.

Minimum Skills, Knowledge and Abilities

• 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)

Physical Demands

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.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Schedule

Must be flexible on schedule and hours. Some Travel may be required.