From intake to outcomes, CareMetx is dedicated to delivering industry-leading patient access solutions and support services that help patients quickly start and stay on specialty therapy treatments. We provide scalable, efficient digital hub services for pharmaceutical companies and healthcare providers, streamlining workflows with seamless integration for patient enrollment, consent, and prior authorization. Our best-in-class patient support services enhance every step of care, connecting patients, providers, and brands to drive better outcomes and accelerate time-to-therapy.
JOB TITLE: Field Reimbursement Manager
POSITION SUMMARY:
Under the general supervision of the Program Operations leadership team, the Field Reimbursement Manager will serve as a field or home-office based regional expert in payer policies, will handle escalated reimbursement issues and will provide support to healthcare providers in order to facilitate appropriate patient access and utilization of services to ensure their access to care.
PRIMARY DUTIES AND RESPONSIBILITIES:
- Interact with key stakeholders within healthcare provider clinics, physician practices, or hospital outpatient locations.
- Act as a liaison between healthcare provider offices and CareMetx program teams to support complex reimbursement cases.
- Take the lead on complicated or escalated reimbursement cases in assigned territory, navigating options for both patients and providers to access prescribed therapies for patients.
- Validate Prior Authorization and Appeal Requirements and communicate as needed to stakeholders.
- Track electronic payer billing codes for pharmacy and medical payers.
- Develops Appeal Package for patient support program; ensures communication occurs between stakeholders on status of Appeal, if applicable
- Coordinates with patient support program representatives.
- Assist program teams with handling escalated medical and pharmacy billing challenges.
- Assist with resolving reimbursement challenges.
- Provides information on relevant reimbursement topics related to our client’s products.
- Educate clinics/physician’s offices on patient support program and services.
- Effectively communicates with patients, family, provider, manufacturer and team members.
- Provides exceptional customer service to internal and external customers resolves any customer request in a timely and accurate manner, escalates complaints accordingly.
- Assist in development of standard operating procedures regarding payer creation, payer database management and prior authorization forms library.
- Verifies transactions and processes comply with organizational and departmental policies and procedures; suggests changes and solutions as appropriate.
- Independently and effectively resolves complex accounts with minimal supervision.
- Handles complex issues where analysis of situations or data requires an in-depth evaluation of variable factors.
- Networks with key contacts outside their own area of expertise.
- Acts independently to determine methods and procedures on new or special assignments.
- Exercises judgment in selecting methods, techniques and evaluation criteria for obtaining results.
- Maintain regular and reliable attendance, including being present, on time, and prepared for work as scheduled.
- Performs related duties as assigned.
EXPERIENCE AND EDUCATIONAL REQUIREMENTS:
- 5 + years’ experience working with specialty healthcare providers for both pharmacy and medical billing (including buy and bill), reimbursement, patient assistance programs, financial assistance programs, and other pharmaceutical reimbursement related activities.
- Experience with Retinal is highly preferred.
- Technical knowledge of healthcare reimbursement including coding, billing, appeals process, and navigating complex reimbursement issues with both patients and providers.
- Advanced degree or specific Practice Management experience preferred
MINIMUM SKILLS, KNOWLEDGE AND ABILITY REQUIREMENTS:
- Ability to communicate effectively both orally and in writing.
- Ability to build productive internal/external working relationships.
- Strong interpersonal skills and attention to detail.
- Ability to manage multiple tasks.
- Strong analytical skills.
- Excellent presentation skills
- Advanced knowledge of medical insurance terminology
- Strong teamwork abilities
- Project management skills
- Ability to work independently
- Knowledge of Centers of Medicare & Medicaid Services (CMS) policies and processes, Pharmacy Benefit design and coverage policy a plus
- Strong organizational skills; attention to detail.
- Ability to resolve associate issues effectively and efficiently.
- Ability to proficiently use Microsoft Excel, Outlook and Word.
- Proven ability to appropriately escalate issues to management.
- Knowledge of private payer, Medicare and Medicaid structure systems and reimbursement processes.
- Understanding of patient privacy laws including HIPAA and similar state laws
- Ability to travel and cover large multistate geography territories, at least 50% travel required, based on geography and territory
- Ability to travel overnight
- Live within 45 minutes’ drive of major airport.
- Ability to schedule individual work-related travel (air, hotel, rental car as needed).
- Ability to utilize own car for travel.
- Technical knowledge of healthcare from a patient and provider perspective (miscellaneous codes, billing codes, appeals process).
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit.
- The employee must occasionally lift and/or move up to 10 pounds.
WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.The noise level in the work environment is usually moderate.
SCHEDULE:
- Must be flexible on schedule and hours
- Some travel may be required
CareMetx considers equivalent combinations of experience and education for most jobs. All candidates who believe they possess equivalent experience and education are encouraged to apply.
At CareMetx we work hard, we believe in what we do, and we want to be a company that does right by our employees. Our niche industry is an integral player in getting specialty products and devices to the patients who need them by managing reimbursements for those products, identifying alternative funding when insurers do not pay, and providing clinical services.
CareMetx is an equal employment opportunity employer. All qualified applicants will receive consideration for employment and will not be discriminated against based on race, color, sex, sexual orientation, gender identity, religion, disability, age, genetic information, veteran status, ancestry, or national or ethnic origin.
