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Specialist, Reimbursement and Appeals Santa Monica United States,  

Job Score (company)

Posted on : 26 February 2017

Project Description

  • 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.

Responsibilities (include but are not limited to):
  • 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 

Key attributes:
  • 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 
  • Customer-focused 
  • Business acumen / business savvy 

Work experience:
  • 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 

About Us:
  • 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. 


Santa Monica CA

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