Job DescriptionThe Payer Relations Director (PRD), is a remote, home based position and is responsible for the successful coverage and reimbursement as well as the overall management of coverage, coding, and reimbursement processes within an assigned region encompassing commercial insurance, MAC(s), Medicaid. Successful performance will include establishing favorable payer coverage, ensuring fair and consistent payment, and removing barriers in the overall reimbursement process. The position is also responsible for the coordination and execution of reimbursement support for KOL healthcare providers that are influencers within the assigned geography on payers, state societies to impact favorable coding, coverage and access. The PRD partners with the Glacoma Reimbursement Liaison Team and RL leadership team to deliver consultations with KOL physicians and institutional customers through specialized services to assist with reimbursement barriers. This position interacts with a variety of customers to include; medical directors, MAC medical policy staff, MAC case managers, CMS MAC medical directors and staff, state government health staffers, state society and advocacy groups, KOL physicians, hospital and ASC staff. They will serve as an expert in payer policies and provide support to facilitate appropriate coverage, payment, patient access and utilization of services to ensure their access to care. The PRD will promote collaboration with the Sales, Customer Relations, Reimbursement Liaisions, and Medical Affairs teams to achieve payer and provider strategic business goals along with build the relationships and foundation with key healthcare stakeholders to establish a foundation for coding, coverage and payment for future technologies. This candidate must be organized and detail-oriented. Demonstrated teamwork abilities with high emotional intelligence in managing multiple business initiatives and cross-functional relationships with key internal and external healthcare stakeholders will be a requirement to achieve their goals.
Responsibilities- Develop and execute strategies for targeted national and regional plans, as well as MAC/Medicaid that is designed to secure coverage for newly-marketed products, maintain coverage for existing products, minimize barriers to access, solve reimbursement issues, and support sales for Glaukos marketed products.
- Work closely with the Sales Leadership and field sales representatives to appropriately support KOL health care providers with their reimbursement needs.
- Develop sustainable corporate relationship that will allow for continued growth of current and future technologies.
- Understand and work with key health care stakeholders within the following customers:
* Commercial Managed Care (Regional Plans)
* Medicare (Part A, B, C, D; Carriers)
* Medicaid (Fee for Service, Managed Care Organizations)
* State Government Health Staffers
* Veteran's Administration (VISNs)
* TRICARE Regional Offices
* Specialty Pharmacy & Pharmacy Benefit Managers
* Medical Groups
* State Advocacy, patient, provider and other key healthcare stakeholder groups - Required outreach and networking with state/local KOL provider, patient and healthcare systems advocacy organizations.
Qualifications- Bachelor's Degree required
- Advanced degree or specific Practice Management experience
- 15+ years of relevant industry experience
- At least 10 years of Payer medical devices and biologics experience, ideally with injectable buy and bill drugs. Direct biologic launch experience highly desirable. Ophthalmology experience preferred.
- In depth knowledge of the buy and bill system.
- 10+ years of reimbursement and account management experience preferred.
- Minimum 2 years of experience in: practice management, or practice billing and revenue cycle; experience with public or private third-party reimbursement related to product access impact on providers; or experience in pharmaceutical or managed care industry reimbursement including provider site reimbursement interactions
- Knowledge of private payer, Medicare and Medicaid structure systems and reimbursement process.
- Technical knowledge of health care reimbursement from a patient and provider perspective (T codes, miscellaneous J codes, billing coding, appeals process)
- Knowledge of reimbursement policies and hotline database systems.
- Ability to travel overnight for 3-4 nights per week; 50+% travel
- Strong communication skills; ability to effectively interact with all healthcare stakeholders.
- Ability to analyze and interpret regulation and legislation.
- In depth knowledge and understanding of AdvaMed, MDMA. BIO and PHARMA Guidelines.
- Project management skills and the ability to work independently.
