Senior Field Reimbursement Specialist- Cell and Gene Therapy/Rare Disease

Cencora•USA > PA > Remote, PA

6d•$93,500 - $187,000•Remote

About The Position

The Sr Field Reimbursement Specialist (FRS) will plan and engage with health systems, hospitals, academic medical centers, authorized treatment centers, and other institutional stakeholders to provide education on access, reimbursement, and operational considerations relevant to an assigned client’s rare disease cell and gene therapy (CGT) product. This role requires demonstrated experience working within health systems and navigating complex institutional reimbursement, treatment-site readiness, payer coverage, prior authorization, billing, coding, and patient access processes. The Sr FRS will serve as a field-based reimbursement and access subject matter expert, leveraging client-approved resources to support appropriate product access while operating in accordance with established rules of engagement, client legal/compliance guidance, and applicable policies. The role will work within a matrix environment to collaborate with internal and external stakeholders, including client field teams, payer/access teams, patient support program representatives, health system administrators, pharmacy teams, billing and finance teams, and clinical operations stakeholders. Manage daily activities that support appropriate patient access to the client’s products within health systems, hospital outpatient departments, academic and community institutions, authorized treatment centers, and aligned provider offices. This role will act as a liaison to patient assistance, reimbursement support, and access services offered by the client, with a focus on helping institutional stakeholders understand product acquisition pathways, CGT-specific prior authorization requirements, site-of-care considerations, coding and billing requirements, denial and appeal processes, and operational logistics that may affect timely access for patients with rare diseases. The scope and approach to the activities are defined by the client’s legal and compliance departments and may vary.

Requirements

Bachelor’s degree preferred.
Minimum of 7 years of relevant experience, including experience in field reimbursement, health system access, patient access, market access, revenue cycle, managed care, or institutional reimbursement support.
Demonstrated experience working within health systems, hospitals, academic medical centers, authorized treatment centers, or comparable institutional settings required.
Experience with rare disease, cell and gene therapy, specialty biologics, oncology/hematology, neuromuscular disease, or other complex therapeutic areas strongly preferred.
Progressively responsible experience in field reimbursement, patient access, market access, revenue cycle, managed care, provider support, pharmaceutical/biologic support programs, or a related healthcare access role, with demonstrated experience working directly with health systems, hospitals, academic medical centers, authorized treatment centers, and/or large institutional accounts.
Experience supporting rare disease, specialty pharmaceutical/biologic, or cell and gene therapy products is strongly preferred, including familiarity with the access, reimbursement, operational, and logistical challenges associated with high-cost, low-volume, one-time or curative treatment paradigms.
Candidates must possess a Prior Authorization Certification Specialist (PACS) credentials from an industry approved licensing body, or obtain certification within the first six months of employment.
Ability to effectively manage multiple client relationships (e.g., field sales, payer team, support services vendor representatives) and customer.
Ability to manage and support external meetings, presentations, and client interactions.
Ability to lead and work in a matrix environment.
Proven teamwork and collaboration skills with a demonstrated record of accomplishment of working in highly matrixed and cross-functional organizations.
Ability to manage multiple tasks, timelines, expenses, and other activities necessary to fulfill the roles and responsibilities of a Field Reimbursement Specialists.
Ability to effectively work with other client’s program vendors to deliver a positive customer experience.
Sound judgment and decision-making ability with a high degree of emotional intelligence.
Creative problem-solving skills.
Ability to effectively manage competing priorities with a keen sense of urgency.
Demonstrated territory and coordination management skills.
Results oriented.
Excellent communication skills with the ability to present complex information in both informal and formal settings.
Ability to build and maintain effective relationships with business partners and healthcare professionals.
Broad understanding of health system reimbursement, physician buy-and-bill, institutional billing, specialty distribution, specialty pharmacy, assignment of benefits, and alternate sites of care.
Deep understanding of medical and pharmacy benefits, payer policies, utilization management criteria, prior authorization, medical necessity documentation, and appeal requirements for complex therapies.
Understands the dynamics of Specialty Pharmacy vs. Specialty Distribution.
Ensure processes are in place to drive pull through by providing education and resolution on reimbursement and access related issues.
Ability to conduct field-based reimbursement and access support, education, and consultation to key account customers and cross-functional partners.
Experience in revenue cycle, buy-and-bill, institutional billing, benefit investigations, prior authorization, coding, denial and appeals processes, formulary/medical policy navigation, and reimbursement strategies for high-cost specialty products.
Knowledge of private payer, Medicare, Medicaid, state Medicaid, and CMS structures, systems, policies, utilization management criteria, and evolving payment models relevant to rare disease and cell and gene therapy products.
Understanding of authorized treatment center certification, REMS obligations if applicable, treatment-site readiness, patient cell collection workflows, manufacturing timelines, product delivery coordination, and continuity-of-care considerations for CGT products.
Ability to educate health system stakeholders on CGT-specific reimbursement considerations, including applicable coding, NTAP eligibility, pass-through payment status, acquisition cost considerations, payer credentialing barriers, and reimbursement gap mitigation strategies.
Understanding of, and ability to, educate on pharmaceutical manufacturer patient support programs, including financial and co-payment assistance programs.
Listens and responds appropriately to customer needs and questions.
Serve as team subject matter expert on a specific topic, providing routing training to team.
Strong presentation skills, especially effective in small groups.
Above average computer skills: MS PowerPoint, MS Excel, MSWord, and MS Outlook.

Nice To Haves

Experience with rare disease, cell and gene therapy, specialty biologics, oncology/hematology, neuromuscular disease, or other complex therapeutic areas strongly preferred.
Experience supporting rare disease, specialty pharmaceutical/biologic, or cell and gene therapy products is strongly preferred, including familiarity with the access, reimbursement, operational, and logistical challenges associated with high-cost, low-volume, one-time or curative treatment paradigms.

Responsibilities

Educate health systems, hospitals, academic medical centers, authorized treatment centers, and provider office staff on payer coverage, benefit design, and reimbursement considerations for rare disease and cell and gene therapy products
Validate and educate stakeholders on prior authorization requirements, including clinical eligibility criteria, site-of-care requirements, payer-specific medical necessity documentation, and appeal processes
Demonstrate understanding of specialty pharmacy, specialty distribution, buy-and-bill, and institutional acquisition pathways, including the unique operational considerations associated with CGT products
Educate institutional stakeholders on coordination needed to support product access, including infrastructure needed for treatment-site readiness, authorized treatment center certification, REMS obligations if applicable, patient cell collection, manufacturing timelines, product delivery scheduling, and monitoring requirements
Educate health system administrators, pharmacy teams, billing and finance teams, and provider office staff on coverage management strategies, product acquisition channels, formulary placement, coding, billing, prior authorization, denial, and appeal processes
Identify alternate funding, financial assistance, copay support, foundation support, and other appropriate access resources for eligible patients, consistent with client-approved guidance
Act as a subject matter expert on coverage, payer policy, product-specific codes, institutional reimbursement requirements, and patient-specific access questions, including CGT-related reimbursement considerations such as HCPCS/CPT codes, NTAP eligibility, pass-through payment status, and reimbursement gap mitigation strategies
Apply effective account management within complex health systems by uncovering customer insights, identifying account-level access barriers, using critical thinking and problem solving, and disseminating information to appropriate internal and external partners
Review and educate on appropriate billing and coding considerations for a rare disease / CGT product, including institutional billing workflows, buy-and-bill requirements, and potential reimbursement gaps relative to acquisition cost
Probe to understand health system and office processes and discern root causes of access, reimbursement, treatment-site readiness, payer credentialing, or logistical barriers
Drive resolving reimbursement issues through an educational approach
Educate stakeholders on evolving CGT reimbursement constructs, which may include outcomes-based agreements, installment or annuity payment models, value-based contracts, and applicable CMS payment models, as directed by the client
Monitor, identify, and communicate local and regional payer coverage trends, including commercial payer criteria, Medicare and Medicaid considerations, local and national coverage determinations, and state Medicaid participation in applicable CGT access models
Coordinate with authorized treatment center site coordinators, pharmacy teams, cell collection centers, patient support program representatives, and other stakeholders to support operational readiness and continuity of care
Collaborate with our client’s patient services program representatives
Educate institutional and provider office staff on the use of the client’s patient assistance and reimbursement support services, including web-based provider programs and patient support program processes
Deliver interactive educational presentations and in-services at health systems, hospitals, authorized treatment centers, academic medical centers, and provider sites of service
Provide information on relevant reimbursement topics related to our client’s products based on client’s approval
Communicate and collaborate with client cross-functional teams to include but not limited to sales representatives, account managers and district managers based on established rules of engagement
Prioritize activities and abide by approved processes to maximize effective coverage of assigned accounts, maintain awareness of the low-volume, high-complexity nature of rare disease patient populations, and track progress while adhering to policies, procedures, and performance metrics
Leverage reimbursement knowledge and utilize resources to aid accounts and effectively build customer partnerships
Lead internal team training and meetings
Serve as a peer buddy and mentor to colleagues
Lead geography support for team members and manager
Develop and execute business plan for assigned territory
Performs other related duties as assigned.