Manager, Payer Access and Reimbursement

Overview :

The Manager supports Payer Access & Reimbursement (PAR) activities as a member of a cross-functional team, oriented to Medical Affairs (MA) activities related to medical access, evidence generation, value proposition creation, and coverage in policy, all of which impact the reimbursement of Quest’s portfolio of tests.

This individual proactively brings expertise in the reimbursement of laboratory medicine to build and execute key strategic initiatives and decision points.

The Manager is instrumental in the coordination of internal strategic and procedural activities related to enhancing third-party coverage and reimbursement of Quest products with emphasis on oncology, particularly minimal residual disease (MRD) testing.

This individual must possess an extensive medical knowledge with strong analytic, problem solving, decision making and presentation capabilities to help facilitate the coverage and reimbursement process as it relates to stakeholders’ interests, while mitigating risk for the organization.

This is a Remote opportunity

Responsibilities :

Identify when a medical appeals strategy is necessary, then implement and coordinate the appeals strategy for designated products in conjunction with Payer Access leadership and cross-functional teams.

Communicate with cross-functional partners the plans, lines of business, and clinical indications for which appeals are to be implemented.

Facilitate the creation and approval of supportive letters with appropriate medical content to accompany claims at each level of appeal.

Identify the appropriate medical appeals letter to be submitted for each claim, based on clinical indication / testing use case

Coordinate with cross-functional partners for medical records documenting pertinent content for claims appeals.

Where automation of appeals is infeasible, work with cross-functional partners to develop / execute a successful strategy for manual appeals.

Monitor the submission success and outcomes of efforts. Document progress of activities including appropriate metrics and reporting platforms.

Assist in the execution of MA strategies aligned with business needs and the evolving external health system environment (private and government payers, regulatory environment) for optimal utilization and reimbursement of Quest products with emphasis on oncology, particularly MRD.

Identify and harness opportunities to improve coverage and reimbursement (C / R) for assigned Payer Access category in all phases (e.

g., idea to market, lifecycle management).

Execute and / or inform strategies based on root causes of denials.

Evaluate coverage landscape and focus on clinical utility.

Leverage and coordinate internal / external stakeholders and resources to identify and address C / R opportunities. Collaborate with cross-functional teams (e.

g., other MA teams, Clinical Franchises, Health Plans, Billing, Coding / Compliance / Legal) to develop Payer Access strategies to optimally support business needs.

Collaborate with other internal Quest teams as needs arise.

Maintain knowledge of all assigned disease states, products, relevant changes in medical and reimbursement policies, and changes in payer procedures.

Ensure incorporation into the short and long-term business plans.

Performs other functions of the MA department as needed.

Qualifications :

Required Work Experience :

6 years’ experience between the following : Medical knowledge and healthcare experience (e.g., Laboratory, Clinical, Health Systems, Genetics, Molecular)

Payer policy / claims procedures (e.g., medical / reimbursement policy, billing and coding)

Preferred Work Experience :

8 years’ experience between the following : Clinical experience in Oncology

Medicare appeals for laboratory services

Laboratory medicine (e.g., cytotechnologist, microbiologist, molecular variant scientist, laboratory genetic counselor)

Payer policy / claims procedures (e.g., medical / reimbursement policy, billing and coding)

Physical and Mental Requirements :

Ability to execute concurrent projects

Adaptable to abrupt changes in projects based on external influences / internal business needs

Strategic mindset

Communication

Knowledge :

In-depth knowledge of medical terminology and medical conditions.

Demonstrated understanding of the healthcare, health insurance, Medicare / Medicaid, and regulatory environments.

Skills :

Strong time management

Strong written and oral communication skills

Collaborative approach in cross-functional team settings

Intermediate-advanced skills in using Microsoft™ Word, Excel, and PowerPoint software packages. Intermediate-advanced skills in Smartsheet.

Education :

Bachelor’s degree in a relevant discipline (e.g., life sciences, health / public policy)

EEO :

Equal Opportunity Employer : Race / Color / Sex / Sexual Orientation / Gender Identity / Religion / National Origin / Disability / Vets