Director, Commercial Reimbursement

This is a fully remote position, open to applicants in United States.

📋 Description

• Create and implement commercial reimbursement strategies that align with the company's objectives and growth initiatives.

• Lead interactions with national, regional, and local commercial health plans, engaging with medical directors and policy teams.

• Drive initiatives to influence, establish, or modify commercial payer medical policies, which includes:

• Challenging determinations of non-coverage, including designations of “Investigational and Experimental.”

• Addressing restrictive utilization criteria.

• Supporting suitable coverage pathways.

• Oversee the escalation of payer policy disputes and coverage challenges that cannot be resolved through standard operational channels.

• Advocate for efforts to secure appropriate reimbursement in instances of commercial payer underpayment.

• Provide leadership regarding payer positioning, value messaging, and the reimbursement implications of payer decisions.

• Act as the primary contact for commercial reimbursement in payer negotiations and senior-level escalations, including direct engagement with medical directors and payer leadership.

• Coordinate and assist with peer-to-peer, appeal, and reconsideration efforts involving clinical and provider stakeholders.

• Utilize a comprehensive understanding of commercial payer processes, timelines, and decision-making frameworks.

• Support in identifying and developing physician champions to enhance payer engagement activities.

• Collaborate with providers to resolve reimbursement issues across outpatient service sites.

• Ensure reimbursement strategies are in sync with real-world site-of-care dynamics and the operational needs of providers.

• Directly manage and lead the Market Access Manager team.

• Establish and uphold standardized processes, tools, and best practices to guarantee consistent field execution.

• Define performance expectations, mentor team members, and facilitate ongoing development.

• Serve as the escalation point for intricate, high-risk, or precedent-setting reimbursement issues with significant access, revenue, or policy implications, including direct payer involvement when needed.

• Collaborate with Commercial, Sales, Medical Affairs, Legal, Compliance, and Finance teams to ensure integrated reimbursement planning and compliant execution.

• Provide reimbursement guidance to facilitate commercial planning, launch readiness, and field enablement.

• Represent commercial reimbursement viewpoints in cross-functional forums and leadership discussions.

• Develop metrics and reporting to evaluate reimbursement performance and identify areas of risk or opportunity.

• Utilize payer policy data and claims insights to guide strategic prioritization, escalation decisions, and payer engagement strategies, including recognizing issues that necessitate senior-level intervention.

• Drive ongoing improvements in reimbursement strategy and operational effectiveness through data-informed insights.

⛳️ Requirements

• Bachelor’s degree required; advanced degree preferred (health policy, health services administration, public health).

• Minimum of 8 years of progressively responsible experience, including roles similar to a Senior Manager or Director, in reimbursement, market access, or payer relations within the medical devices or healthcare sector.

• Proven experience working with commercial health plans, encompassing policy review, coverage advocacy, and payer negotiations.

• Strong understanding of prior authorization, claims processing, and appeals within outpatient settings in commercial health plans.

• Experience with commercial payer data sources and claims datasets (e.g., payer policy intelligence platforms or DHC type claims data) to support coverage analysis, denial trends, and reimbursement decision-making.

• Familiarity with coding, payment, and site-of-service considerations across various care settings.

• Experience collaborating with physicians to facilitate payer discussions or appeal strategies.

• Prior experience in people management with accountability for team performance and development.

• Ability to effectively communicate across various departments and functions; manage the completion of multiple tasks.

• Ability to prioritize projects while demonstrating initiative and flexibility. Detail-oriented with strong organizational skills.

• Excellent oral presentation skills, both via teleconference and in-person.

• Strong technical, written, and communication skills.

• Proficiency in productivity software, including Microsoft Office (Word, Excel, Outlook, PowerPoint, etc.).

• Willingness and ability to maintain current hospital credentialing requirements, including all necessary vaccinations and immunizations.

• Travel: up to 40%.

• Work location: Remote.

• Full-time employment.

• Must be able to sit for up to 8 hours a day.

🏝️ Benefits

• A competitive base salary range of $210,000 - $225,000 along with a variable incentive plan.

• Stock options that provide ownership and a stake in a mission-driven company.

• An employee benefits package that includes 401(k), healthcare insurance, and paid vacation.