Director, Reimbursement Strategy – Patient Access Excellence

This is a fully remote position, open to applicants in Kentucky, +2 more states.

📋 Description

• Act as the leading subject matter expert for specialty pharmaceutical reimbursement, focusing on GLP-1 medications.

• Offer insights regarding commercial insurance, Medicare, Medicaid, pharmacy benefits, and medical benefit frameworks.

• Analyze payer requirements, formulary limitations, step therapy protocols, prior authorization standards, and coverage restrictions.

• Recognize reimbursement trends, alterations in payer policies, and obstacles to patient access.

• Formulate recommendations to enhance reimbursement accuracy, processing efficiency, and patient access results.

• Address complex prior authorizations, benefit inquiries, coverage rejections, appeals, and reimbursement challenges.

• Provide guidance to Reimbursement Analysts and operational leadership on technical issues that require escalation.

• Collaborate with prescribing providers, authorized clinical resources, and client stakeholders.

• Assess workflows and suggest enhancements for efficiency, accuracy, consistency, and scalability.

• Assist in root-cause analysis of processing mistakes, aged cases, preventable denials, and operational inefficiencies.

• Deliver technical coaching, onboarding assistance, ongoing education, and skill development for Reimbursement Analysts and SMEs.

• Create payer-specific knowledge resources, technical guidance documents, standard operating procedures, and escalation protocols.

• Engage in quality calibration sessions.

• Advise clients and senior stakeholders on payer trends, barriers to reimbursement, process enhancements, and opportunities for patient access.

• Support the launch of programs, transition of processes, operational readiness, and scalability of programs.

• Assist in defining technical competencies and proficiency expectations for analysts and SMEs.

• Promote uniform reimbursement practices across diverse delivery locations.

• Work in partnership with Operations, Quality Assurance, Training, client stakeholders, and other functional partners.

⛳️ Requirements

• Bachelor's degree in healthcare administration, business, pharmacy-related fields, or a similar discipline, or an equivalent combination of education and directly relevant experience.

• 8–10+ years of progressive experience in pharmaceutical reimbursement, patient access, specialty pharmacy, healthcare revenue cycle, or related healthcare insurance operations.

• 3+ years of Director-level experience or equivalent senior functional leadership experience focused on reimbursement strategy, complex escalation management, or cross-functional patient access initiatives.

• Advanced expertise in benefit investigations, prior authorizations, appeals, coverage determinations, payer policy interpretation, and reimbursement workflows.

• Proven track record of resolving intricate pharmaceutical reimbursement and patient access issues.

• Background in providing strategic advisory support to operational leaders, client stakeholders, or senior healthcare professionals.

• Ability to convert technical reimbursement knowledge into practical operational solutions.

• Experience in coaching, mentoring, or providing technical guidance to reimbursement professionals.

• Strong analytical, problem-solving, communication, and stakeholder management skills.

• Familiarity with HIPAA, patient confidentiality, and relevant healthcare reimbursement compliance standards.

• Willingness to remain actively involved in detailed reimbursement workflows while offering senior-level guidance.

• Preferred: Direct experience with GLP-1 therapies and payer requirements concerning Type 2 diabetes and chronic weight management.

• Preferred: Experience within pharmaceutical manufacturer patient support programs, specialty pharmacy services, patient access hubs, or reimbursement support organizations.

• Preferred: Knowledge of commercial payer and government program coverage policies.

• Preferred: Experience in supporting reimbursement operations in a business process outsourcing or third-party service environment.

• Preferred: Experience aiding large-scale or rapidly growing reimbursement teams.

• Preferred: Familiarity with electronic prior authorization systems, payer portals, CRM platforms, and case management applications.

• Preferred: Relevant pharmacy technician registration, professional certification, or specialized reimbursement credentials, as applicable.

🏝️ Benefits

• Full-time employment.

• Remote work opportunities available within Kentucky, Tennessee, or Virginia.