Job Summary
The preferred candidate comes with a successful track record in developing and executing profitable market access and contract strategies with distribution networks, wholesalers, specialty durable medical equipment, pharmacy providers (SPPs) and pharmacy benefit managers (PBMs). The candidate should have a strong understanding of and existing relationships with the pharmacy/Durable Medical Equipment department and clinical policy department personnel at many of the national commercial payers and the top 10-30 regional commercial payers. The candidate should also have knowledge of orthopedic/neurosurgeon specialty/durable medical equipment administered in the physician office setting and reimbursed through both medical and pharmacy channels. The candidate must be versed in federal, state and third-party payer systems; Medicare and Medicaid reimbursement in the DMEPOS space; and recent national healthcare reform. This includes a working knowledge of pricing requirements and ASP calculations for various federal and state healthcare programs; a thorough understanding of reimbursement systems and processes for coverage policy development with public and commercial payers; the ability to establish and accomplish strategic and daily priorities; experience negotiating and implementing pharmaceutical contracts; strong verbal and written communication skills; is a team player; and produces results.
Additionally, the preferred candidate has a proven track record of success working with integrated delivery networks, hospital DME departments, and physician practices to create access to specialty DME administered in the physician office setting.
Principal Duties and Responsibilities
- Fully accountable for the development and execution of profitable managed markets and DME specialty distribution strategies in the designated market segments.
- Proactively manage relationships with assigned accounts and develop new relationships that allow for increased access and sales opportunities for assigned products.
- Align with entire Revenue Cycle Management (RCM), Payer Relations and Contracting team in the development of pricing and contracting strategy for assigned products.
- Oversight of Contract Management and Pricing team and processes
- Experience with DME accreditation, credentialing, licensing and onsite auditing protocols
- Networking relationships with top DME payers and medical policy consultants and analysts
- Manage cadence of receipt of and collaborating with appropriate stakeholders to ensure timely submission of responses to RFPs within gross-to-net contract guidelines in designated market segments.
- Make recommendations on all contract management policies, procedures, and financial matters to Payer Relations Management.
- Responsible for promoting ideas to management for alternative strategies to test innovative opportunities in a rapidly evolving marketplace.
- Create, utilize, and be able to decipher complex analytics related to the assigned product segment.
- Assess potential liability of adverse market conditions to the company and quantify impact.
- Problem solves with internal stakeholders – including payer relations team, sales team, commercial team and the product engine on relevant issues.
- Perform special projects as assigned from Payer Relations and RCM leadership.
This is not an exhaustive list of duties or functions and may not necessarily comprise all the "essential functions" for purposes of the ADA.
Expected Areas of Competence (i.e., KSAs)
- Well-developed analytical, problem solving, and influencing skills.
- Demonstrated ability to successfully managed high impact relationships, contracts, and projects.
- Demonstrated ability to work well in teams.
- Excellent communication (written, verbal, and presentation) skills with ability to interact with all levels of management for both internal and external customer base.
- Ability to work effectively and independently from a home office and field-based setting.
- A track record of utilizing tact and diplomacy to achieve mutually beneficial goals for an organization.
- Highly developed time management skills with demonstrated ability to meet deadlines and handle multiple priorities with a high degree of initiative required.
- Strong organizational skills.
- Strong understanding of commercial payers, CMS, Medicare, and state legislative DME & Pharmaceutical licenses/policy issues related to enrollments, pricing, and reimbursement of company products.
- Knowledge of reimbursement of medical/physician administered DME/pharmaceuticals in all settings of care.
- Awareness of legal and compliance issues around DME/pharmaceutical pricing and reimbursement.
- Understanding of health outcomes, economic and other value as drivers of optimal price.
- Understanding of DME/pharmaceutical distribution and supply chain processes.
- Experience in budgeting and forecasting.
- Creativity and negotiation skills.
- Strong computer and financial modeling skills; Microsoft Office - MS PowerPoint, MS Excel, MS Word, and MS Outlook.
Education/ Experience Requirements
- BA/BS or equivalent required. Advanced degree and/or course work preferred.
- Professional Experience: Significant market access, contracting, and strategic experience. 6-8 years broad-based relationship management, contracting and strategic experience across commercial operations. Current knowledge of DME/pharmaceutical industry and trends, particularly involving physician-administered specialty DME.
Travel Requirements