Senior Field Reimbursement Specialist- Cell and Gene Therapy/Rare Disease

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Job Details

Please note:

This position is open to qualified candidates located anywhere in the United States. Candidates are not required to reside in a particular state; however, they must live within a reasonable commuting distance of a major airport and be able to travel up to 80% as required by the role.

T he Sr Field Reimbursement Specialist (FRS) will plan and engage with health systems, hospitals, academic medical centers, authorized treatment centers, and other institutional stakeholders to provide education on access, reimbursement, and operational considerations relevant to an assigned client’s rare disease cell and gene therapy (CGT) product.

This role requires demonstrated experience working within health systems and navigating complex institutional reimbursement, treatment-site readiness, payer coverage, prior authorization, billing, coding, and patient access processes. The Sr FRS will serve as a field-based reimbursement and access subject matter expert , leveraging client-approved resources to support appropriate product access while operating in accordance with established rules of engagement, client legal/compliance guidance, and applicable policies.

The role will work within a matrix environment to collaborate with internal and external stakeholders, including client field teams, payer /access teams, patient support program representatives, health system administrators, pharmacy teams, billing and finance teams, and clinical operations stakeholders.

Manage daily activities that support appropriate patient access to the client’s products within health systems, hospital outpatient departments, academic and community institutions, authorized treatment centers, and aligned provider offices.

This role will act as a liaison to patient assistance, reimbursement support, and access services offered by the client, with a focus on helping institutional stakeholders understand product acquisition pathways, CGT-specific prior authorization requirements, site-of-care considerations, coding and billing requirements, denial and appeal processes, and operational logistics that may affect timely access for patients with rare diseases. The scope and approach to the activities are defined by the client’s legal and compliance departments and may vary.

Activities may include, but are not limited to:

Educate health systems, hospitals, academic medical centers, authorized treatment centers, and provider office staff on payer coverage, benefit design, and reimbursement considerations for rare disease and cell and gene therapy products

Validate and educate stakeholders on prior authorization requirements, including clinical eligibility criteria, site-of-care requirements, payer-specific medical necessity documentation, and appeal processes

Demonstrate understanding of specialty pharmacy, specialty distribution, buy-and-bill, and institutional acquisition pathways, including the unique operational considerations associated with CGT products

Educate institutional stakeholders on coordination needed to support product access, including infrastructure needed for treatment-site readiness, authorized treatment center certification, REMS obligations if applicable, patient cell collection, manufacturing timelines, product delivery scheduling, and monitoring requirements

Educate health system administrators, pharmacy teams, billing and finance teams, and provider office staff on coverage management strategies, product acquisition channels, formulary placement, coding, billing, prior authorization, denial, and appeal processes

Identify alternate funding, financial assistance , copay support, foundation support, and other appropriate access resources for eligible patients, consistent with client-approved guidance

Act as a subject matter expert on coverage, payer policy, product-specific codes, institutional reimbursement requirements, and patient-specific access questions, including CGT-related reimbursement considerations such as HCPCS/CPT codes, NTAP eligibility, pass-through payment status, and reimbursement gap mitigation strategies

Apply effective account management within complex health systems by uncovering customer insights, identifying account-level access barriers, using critical thinking and problem solving, and disseminating information to appropriate internal and external partners

Review and educate on appropriate billing and coding considerations for a rare disease / CGT product, including institutional billing workflows, buy-and-bill requirements, and potential reimbursement gaps relative to acquisition cost

Probe to understand health system and office processes and discern root causes of access, reimbursement, treatment-site readiness, payer credentialing, or logistical barriers

Drive resolving reimbursement issues through an educational approach

Educate stakeholders on evolving CGT reimbursement constructs , which may include outcomes-based agreements, installment or annuity payment models, value-based contracts, and applicable CMS payment models, as directed by the client

Monitor, identify , and communicate local and regional payer coverage trends, including commercial payer criteria, Medicare and Medicaid considerations, local and national coverage determinations, and state Medicaid participation in applicable CGT access models

Coordinate with authorized treatment center site coordinators, pharmacy teams, cell collection centers, patient support program representatives, and other stakeholders to support operational readiness and continuity of care

Collaborate with our client’s patient services program representatives

Educate institutional and provider office staff on the use of the client’s patient assistance and reimbursement support services, including web-based provider programs and patient support program processes

Deliver interactive educational presentations and in-services at health systems, hospitals, authorized treatment centers, academic medical centers, and provider sites of service

Provide information on relevant reimbursement topics related to our client’s products based on client’s approval

Communicate and collaborate with client cross-functional teams to include but not limited to sales representatives, account managers and district managers based on established rules of engagement

Prioritize activities and abide by approved processes to maximize effective coverage of assigned accounts, maintain awareness of the low-volume, high-complexity nature of rare disease patient populations, and track progress while adhering to policies, procedures, and performance metrics

Leverage reimbursement knowledge and utilize resources to aid accounts and effectively build customer partnerships

Lead internal team training and meetings

Serve as a peer buddy and mentor to colleagues

Lead geography support for team members and manager

Develop and execute business plan for assigned territory

Performs other related duties as assigned.

Experience and Education:

Bachelor’s degree preferred.

• •Minimum of 7 years of relevant experience, including experience in field reimbursement, health system access, patient access, market access, revenue cycle, managed care, or institutional reimbursement support.
• •Demonstrated experience working within health systems, hospitals, academic medical centers, authorized treatment centers, or comparable institutional settings required.

Experience with rare disease, cell and gene therapy, specialty biologics, oncology/hematology, neuromuscular disease, or other