The Associate Director, Reimbursement Services is the primary leader of reimbursement efforts for patients referred into the reimbursement support process. This position is responsible for managing reimbursement services staff, execution of the reimbursement verification and authorization process, and for monitoring and reporting on key performance metrics for reimbursement services. This position acts as the primary liaison between reimbursement support staff, Market Access team, and sales. This position works directly with the Director, Market Access and Reimbursement to recommend and implement improvements or changes necessary to react to marketplace dynamics. Strong analytical and presentation skills are required.
· Day to day oversight and management of the Osiris reimbursement services HUB (i.e. Grafix Hotline); lead, train, coach and develop reimbursement services staff.
· Manage new Insurance Verifications (IVR’s) through the reimbursement evaluation process at the hotline, ensuring optimal speed to coverage determination
· Ensure that medical necessity support, including appeal assistance, is effectively deployed in order to support a positive determination, when possible.
· Leverage clinical insights to review and provide guidance to providers on IVR’s in order to improve positive determinations.
· Collaborate with field representatives, as needed, to train and inform provider offices of insurance authorizations or appeals.
· Collaborate with Market Access team for medical policy information and coverage information and updates.
· Triage payer obstacles to the Market Access team for further research and/or management.
· Updates process flows, SOPs, FAQs, scripts, and cheatsheets as needed.
· Hire and train internal reimbursement staff as needed to support reimbursement and hotline.
· Determine and periodically evaluate the appropriate staff structure to effectively and efficiently distribute workload, optimize turnaround times of IVR and PA’s, and maximize Hotline performance.
· Lead monthly conference calls with the commercial leadership team to review performance metrics, new and open reimbursement cases and other critical performance requirements
· Recommend improvements and process changes to hotline services as necessary, within the scope of company compliance guidelines, to support patient and provider needs.
· Ensure utilization of reimbursement database and collaborate with IT/database vendor to ensure the database is meeting our reimbursement process needs.
· Report weekly and as needed on Key Performance Indicators (e.g. turnaround time, approvals, etc.).
· Monitor and assess performance measures including IVR turnaround time (ITT), account documentation and the quality of provider submissions.
· Lead Quarterly Business Reviews with the Market Access team.
· Escalate customer service and data delivery with the hotline systems, as needed, and monitor resolution of those issues.
Qualifications and Skills Required:
· BA/BS degree required. Clinical degree preferred – RN or similar. MBA or advanced degree in a related field preferred
· 5+ years’ experience working with a reimbursement services HUB
· 3+ years in a supervisory role working in a reimbursement HUB
· 5+ years previous pharmaceutical/biotech experience, wound care experience a plus
· Experience working with multiple projects and managing multiple external partners
· Extensive knowledge of reimbursement HUB operations, reimbursement, prior authorization process, managed care, navigating payer departments, and reimbursement processes
· Knowledge of Medicare, Medicaid, and Private Insurer Reimbursement Methodology
· Able to interpret and analyze detailed Medical policies
· Thorough understanding of the benefits investigation process [deductible, out of pocket, benefits exclusions, etc.]
· Experience with the prior authorization process for products/services
· Strong analytical, planning, project management, communication, and organization skills
· Flexibility to work in a fluid, fast-paced environment and respond quickly to new deadlines
· Strong initiative and ability to accomplish objectives without supervision
· Leadership experience and ability to foster a high performing team environment
· Experience as a people manager required
· Strong communication and presentation skills required
· Experience working with reimbursement databases required
· Strong Microsoft Excel and PowerPoint skills
· Osiris HQ based position (Columbia, MD)
· Travel (<10%)
Osiris Therapeutics, Inc. is an Equal Opportunity Employer with a commitment to diversity. Applicants are considered on the basis of individual merit without regard to race, color, national or ethnic origin, gender, gender identity, sexual orientation, marital status, veteran status, pregnancy, age, religion, disability, genetic information, or any other characteristic protected by law.