Specialist, Reimbursement and Appeals - United States
- Our company is a clinical-stage biopharmaceutical company focused on the development and commercialization of novel cancer immunotherapy products designed to harness the power of a patient’s own immune system to selectively target and kill cancer cells.
- Our core technology involves the genetic engineering of T cells, or white blood cells, to express either chimeric antigen receptors (CARs) or T cell receptors (TCRs) for the treatment of advanced solid and hematological malignancies.
- We are on a rapid growth trajectory and have a highly energized and accomplished team.
- Our company is publicly traded with a current market capitalization well over $2 Billion.
- The Reimbursement and Appeals Specialist is responsible for managing all reimbursement activities for oncology patients from benefit investigations, prior authorizations, pre-determinations, to appeals.
- The Reimbursement/Appeals Specialist will be responsible for assisting with gaining coverage for a novel new product in the Oncology space.
- Verifies patient eligibility and conducts complete benefit investigations
- Determines best approach when completing prior authorizations / pre-determinations
- Confirms coverage and identifies any barriers to coverage for a new product
- Educates the payers regarding the new product and monitors adoption and acceptance of product
- Identifies and resolves claims / eligibility issues
- Ensures that all claims submitted to government and private payers comply with applicable federal and state regulations
- Provides timely follow-up on unpaid, denied, and / or short paid claims
- Understands and interprets payer guidelines and policies
- Creates letters of medical necessity
- Drafts, submits, and tracks action on appeal letters, reconsideration and re-determination requests, and other communication within medical payers on behalf of providers and patients
- Interprets clinical information, performs searches for relevant articles and assists the customer through education and clear communication
- Tracks the status of outstanding appeals and trending appeals successes to help develop appeal strategies for specific payers
- Manages an appeal spreadsheet and notifies the program team and managed care department of payer issues related to appeals
- Ensures all timelines and customer commitments are met
- Minimizes obstacles to coverage by using judgment to successfully plan next steps
- Makes constant case assessments and makes informed, methodical decisions throughout a very complex process
- Assists customers to navigate healthcare insurance reimbursement issues through education, information, and exceptional communication
- Supports the Operations Program Manager on program initiatives and departmental goals
- Enters insurance and benefit data into the program system
- Responds to internal team member case-related questions
- Participates in daily informal check-in’s with team
- Attends weekly team meeting
- Responds to emails from internal and external customers that need to be addressed immediately by a reimbursement / appeals specialist
- Excellent oral and written communication, and customer service skills
- Strong writing skills and excellent organizational ability
- Clinical knowledge is preferable but not essential
- Proven ability to think strategically and to prioritize
- Exceptional problem solving skills
- Exceptional computer skills with proficiency in MS Office Suite, specifically MS Word and Excel
- Ability to work enthusiastically with others
- Self-confident and resourceful
- Exhibits initiative, flexibility, and dependability
- Quality work and attention to detail
- Humility and integrity
- Team Player
- Business acumen / business savvy
- Three or more years of reimbursement experience preferably in a pharma / biotech or health services environment specializing in oncology
- Proficiency in healthcare insurance reimbursement including benefit investigation and design, prior authorizations and pre-determinations
- Full understanding of the insurance approval / denial / appeals process; previous direct experience in submitting appeals and advocating for appropriate clinical treatment of patients is highly desired
- Experience navigating through the public and private payers and working through managed care systems
- Undergraduate degree preferred
- Our company is an equal opportunity employer.
- We are able to offer the opportunity to be part of the first 200 employees in this successful, fast growing company.
- A place everyone knows your name and respects your opinion while at the same time offering benefits and time off packages commensurate to any large corporation.