Director / Senior Director, Head of Patient Access & Reimbursement

It is critical that the person has past Commercial rare disease launch, Patient Services, and specialty infused drug distribution experience, and can identify and drive innovative initiatives around US Market / patient access strategy, patient referral and adherence management, patient affordability, operational process and programs, and patient / caregiver customer engagement models. 

The position is a field-based position, and will partner closely with Patient Services, Trade & Distribution, Medical Affairs, Sales, Sales Operations, Marketing, Patient Advocacy, Legal and Compliance teams to identify and remove patient access barriers, and enhance the overall patient and provider treatment experience. 

• Serve as a strategic leader to build and lead a regionally aligned Patient Access & Reimbursement field team 

• Hire, onboard, and facilitate the training of the field-team. 

• Develop the field-based role and ways of working in partnership with the cross-functional Commercial leadership team. 

• Develop a field-based patient access team that serves as the strategic partner to HCPs and sites of care, by delivering billing and coding reimbursement education to support the patient access journey for their DMD families 

• Establish access goals, productivity measures, and ensure account plans are created and executed quarterly / annually. 

• Work collaboratively with cross functional teams, including Commercial Operations to monitor patient scripts through the fulfillment process. 

• Partner with the Patient Services lead to ensure timely identification of access issues and resolution. 

• Create an environment of ongoing learning and development for the field-based team. 

• Work collaboratively with Trade and Patient Services functional leaders to identify process efficiencies with all third-party service providers. 

• Support the creation of stakeholder analytics and Key Performance Indicators (KPIs) to the business that helps improve forecasting, contracting and pricing decisions, timing and general business planning. 

SITE READINESS / ENGAGEMENT: 

• Gain a deep understanding of site capabilities, operational gaps and develop gap resolution plans in partnership with HCPs and sites of care. 

• Engage with institutional leadership, administration, revenue cycle management, finance, managed care team, contracting, pharmacy, prior authorization departments, and care teams  

• Support HCP champion through formulary inclusion/decision process and monitor Pharmacy and Therapeutic Committee timelines to confirm site readiness.  

• Responsible for eliminating and/or significantly reducing barriers to patient access and reimbursement for Capricor’s product portfolio across all payer segments. 

• Support a high-touch patient and caregiver support programs, including site of care referral management, travel logistics, and patient affordability. 

• Support the development of training material, SOP’s, and work instructions as needed to educate around Capricor channel and patient support offerings. 

• Onboard to educate that all sites of care are operationally confident in Capricor’s buy-and-bill and Specialty Pharmacy procurement process, reimbursement support services and tools, including, prior authorization/reauthorization patient enrollment process best practices, and navigation of the denial/appeal process. 

CROSS-FUNCTIONAL SUPPORT: 

• Work collaboratively with Sales leadership to identify access challenges and solutions. 

• Responsible for understanding and upholding Capricor’s Legal and Compliance guidance at a customer and field leadership level related to access, cost and reimbursement issues.  

• Attend regional sales meetings to represent the Patient Access & Reimbursement team. 

• Routinely provide updates to Capricor Sr. Leadership on health of the launch, key access concerns, and collaborative solutions in place to address known access issues. 

• Support distribution provider and vendor quarterly and annual business reviews, and analytic insights to support company quarterly and annual reporting. 

• Monitor the competition to understand how the evolving market will impact current and future market and patient access strategies. 

• Identify and develop Provider Access and Patient Advocacy Groups, Physician Key Advocate Leaders (KALs), and Societal advocates to support disease / product awareness and patient access to Capricor’s product portfolio. 

• Provide subject matter expertise to the broader organization, including HCP access and reimbursement, distribution, and Payer coverage access intelligence.  This includes cross-functional support of corp. training initiatives, content, tools and presentation development in partnership with Training and Cross-Departmental leaders. 

• Work with the Capricor Commercial Ops / analytics team and Sales to map and report on updates in HCP / Patient access, Patient referral, SPP distribution, trend monitoring, and patient out-of-pocket information. 

• Represent Capricor at Key Industry Conferences (e.g. Asembia, Physician Society, Patient Advocacy, etc.). 

Ensure that all activities and interactions are carried out with the highest ethical and professional standards, and that all work is accomplished with quality and in accordance with Capricor values.  

The Director will report to the SVP, Market Access, and will be integral to supporting key business decisions across the organization.  

• Minimum Bachelor’s degree required; sciences or business preferred, MBA or advanced degree a plus. 

• Minimum of 10+ years of overall industry experience in BioPharma, Healthcare services (i.e. hospital Patient case-management, patient support, provider reimbursement, market access, sales, sales management, or training). 

• Minimum 5 years of progressive Patient support, Payer (Gov. and Commercial) and PBM, and Specialty Pharmacy engagement, and patient case-management responsibility. 

• Strong leadership experience, and has led high functioning, self-directed teams. 

• Experience with rare/orphan drugs is required.  Therapeutic area and pediatric infused drug experience is a plus. 

• Product launch experience is required, and company start-up experience is preferred. 

• Demonstrated expertise in reimbursement, coding, claims adjudication, prior authorization processes, appeals management, and provider education 

• Deep understanding of specialty pharmacy, buy-and-bill distribution models, payer policies, government and commercial reimbursement, and the evolving healthcare access landscape. 

• Strong knowledge of provider economics, hospital finance, revenue cycle management, and infusion site operations. 

• Knowledge and understanding of compliance with HIPPA and OIG guidance in the rare disease space  

• Hospital finance, claims processing, and/or billing/coding experience preferred 

• Excellent working knowledge of patient support programs, including reimbursement support, financial assistance adherence programs, etc. 

• Strong understanding of the PA process, denial management, product acquisition via the specialty pharmacy, buy-and-bill, IV infusion J-code, and reimbursement within multiple sites of care  

• Understands both the buy-and-bill process and specialty pharmacy networks, managed care, benefit design, government payers and their impact on product access with excellent working knowledge of evolving market access and reimbursement landscape  

• Demonstrated flexibility to adapt to a changing environment, implement creative solutions to complex problems, and ability to function in a project leadership role. 

• Ability to develop and maintain strong internal and external relationships, including direct collaboration with vendors and other third parties. 

• Demonstrated flexibility to adapt to a changing environment, implement creative solutions to complex problems, and ability to function in a project leadership role. 

• Superior interpersonal, communication, analytical and presentation skills, with great attention to detail. 

• Development and management of a functional budget and ensuring efficient allocation of resources to achieve strategic patient support objectives. 

• Leads with strong business acumen and a compliance mindset. 

• Passionate about patients and building a new commercial organization.  

• Advanced Virtual / Zoom, Microsoft Excel, Word, and PowerPoint skills. 

SUPERVISORY RESPONSIBILITIES: 

• Recruits, interviews, hires, and trains new staff. 

• Provides constructive and timely performance feedback and evaluations. 

• Other related supervisory responsibilities as assigned.
  
  

• Strong problem-solving and decision-making ability.  

• Vendor management and negotiation skills.  

• Works to improve tools and processes within functional area. 

• Ability to work in a fast-paced, rapidly scaling environment.  

• Exceptional attention to detail and documentation discipline.  

• Ability to influence without authority across cross-functional teams. 

• This position a field-based (remote) position, but is expected to be in the San Diego, CA office approximately 2 – 3 times per quarter, or other frequency as required by business necessity or as reasonably required by the position’s manager. 

• Domestic travel will be required up to 50%, based upon business needs.