Payer Policy & Reimbursement Optimization (AD/Director level)

The Role
Our client is seeking an innovative and highly motivated leader for Payer Policy and Reimbursement Optimization to help with payer policy, health economics, reimbursement and payer adoption of our client’s products. Reporting to the SVP of Market Access, the ideal candidate will support the market access and revenue cycle management (RCM) teams as follows:

• Build and sustain scientific/clinical relationships with internal and external stakeholders
• Define and communicate the clinical/economic/quality of life value of Belay’s Product Portfolio across identified payer stakeholders
• establish payer stakeholder strategic alliances, or other collaborations, to drive evidence generation and value-based revenue generating opportunities
• Analyze existing data and inform the development of new research to support initial and ongoing value-based reimbursement strategy of Belay’s Product Portfolio.

Qualifications

• Minimum of 5 years’ experience working with payers to review, draft and implement medical policies supporting value-based coverage and payment for advanced molecular diagnostics, and/or companion diagnostic products (i.e. precision or personalized medicine).
• Working understanding of RCM processes especially prior authorizations and peer-to-peer appeals
• Advanced Health Care degree (PhD, PharmD, RN, MS, CGC, etc.)
• Exceptional scientific writing capabilities and experience writing manuscripts, medical policies, dossiers, and other relevant documents.
• Ability to understand and clearly articulate advanced medical/scientific concepts (e.g., cancer genomics) at a level where they can be effectively understood payers.
• Successful experience building a positive and innovative clinical and health economic value proposition with payers
• Outgoing personal style and proven ability to build and maintain relationships with multiple levels at payers and related organizations (e.g. tech assessment, care management, employers, specialty pharmacy, patient advocacy, etc.)
• Understanding of the CNS clinical “landscape” (e.g., how treatment decisions are made across all CNS cancer patient types).
• Project management experience especially with clinical trials, payer-related coverage “pilots,” or demonstration projects.
• Ability to travel - 30% travel expected for this role

• Established payer relationships a plus.
• Successful track record working in fast-paced, growing organization preferred.

Responsibilities
Work with market access, clinical / med / scientific affairs, RCM and other our client’s stakeholders to:

• Support the RCM Team with reimbursement processes including but not limited to prior authorization, appeals, patient inquiries, payer inquiries and other administrative tasks requiring a clinical expert.
• Define clinical/economic/quality of life (qol) value and evidence roadmap for Our client’s product offerings vs. standard of care (SOC) across the payer continuum
• Publication roadmap
• health economic models
• evidence dossiers
• evidence-based stakeholder education programs

• Engage with Health Technology Assessment organizations (e.g. BCBSA, ECRI, Palmetto MolDx, etc.) and/or Professional Guideline Organizations (e.g. NCCN, ASCO, etc.) to increase the positive assessments of our client’s testing.
• Form strategic payer alliances and develop other initiatives to drive evidence generation and value-based market access opportunities
• pilot studies; demonstration projects
• population health initiatives
• Evaluate and report on payer policies impacting our client’s products and reimbursement.
• Lead evidence-driven payer stakeholder marketing efforts (Payer branding, value messaging, collateral, conferences, programs, etc.)
  • Responsible for clinical and scientific content of documents directed toward payers and the broader reimbursement audience.
  • Assist in the design of clinical utility and health economic studies and in the writing of subsequent manuscripts.
  • Travel with the market access team to payer audiences to present the clinical/scientific aspects of the our client’s product line.
  • Serve as a point person between the market access and RCM teams and the clinical/scientific/commercial functions of the company.
  • Ensure clinical/economic/qol messaging for payers is well aligned with sales and marketing efforts.
  • Take on and complete specific tasks related to payer projects, including but not limited to, payer “pilots” or demonstration projects.
  Personal and Professional Characteristics
  • Demonstrates ability to maintain confidentiality at all levels; acts with integrity.
  • Exhibits patience and approachability, sets positive tone and example for team member behavior, work ethic and quality, abilities, skills, and overall performance.
  • Exhibits effective team leadership abilities.
  • Establishes and maintains solid interpersonal relationships with team members across all levels of an organization.
  • Demonstrates and facilitates professional communication skills; must be able to understand, listen, write, and speak fluently, professionally, and effectively in the English language.
  • Strong attention to detail, analytical, research, and problem-solving skills. Pro-active ability to identify, assess, improve/refine and solve complex challenges, processes, and/or situations.
  • Ability to successfully work collaboratively within a team as well as independently with minimal supervision.
  • Flexible and able to thrive in a fast-paced, high growth, team-based environment while successfully handling competing and ever-changing priorities and responsibilities with frequent interruptions.
  • Solid track record of taking responsibility and holding oneself accountable for high quality task deliverables within established deadlines.
  • Proficient software/computer skills utilizing various applications which includes, but is not limited, to the following: MS Office, accounting/finance database/systems, health care database/systems, etc.
  • Focused on overall team success vs. solely on individual success.