Director, Reimbursement Strategy & Patient Access Excellence

Director, Reimbursement Strategy & Patient Access Excellence

Specialization: GLP-1 & Specialty Pharmaceutical Reimbursement

Department: US Operations – Patient Access / Reimbursement Services
Reports To: Senior Director, US Operations (or designated operational leader)
Employment Type: Full-Time
Classification: Director-Level Individual Contributor / Strategic Subject Matter Expert
Location: United States – Kentucky, Tennessee, or Virginia

Position Summary

The Director of Reimbursement Strategy & Patient Access Excellence serves as a senior-level subject matter expert and strategic advisor responsible for advancing reimbursement expertise, patient access effectiveness, and operational excellence across specialty pharmaceutical reimbursement programs, with an initial emphasis on GLP-1 medications.

This position requires an individual with Director-level industry experience who can combine strategic reimbursement knowledge with hands-on expertise in benefits investigations, prior authorizations, payer policy interpretation, appeals, coverage challenges, and patient financial assistance programs.

The Director will provide specialized guidance to Reimbursement Analysts, operational leadership, training, quality assurance, and client stakeholders to ensure complex reimbursement processes are managed accurately, efficiently, and in accordance with applicable regulatory and payer requirements.

Unlike a traditional departmental Director, this position emphasizes functional expertise, strategic advisory support, reimbursement excellence, and technical leadership rather than direct personnel management.

The successful candidate will be equally comfortable advising executive stakeholders, resolving complex reimbursement barriers, coaching frontline analysts, and supporting the development of scalable reimbursement operations.

Key Responsibilities

1. Reimbursement Strategy & Industry Expertise

• Serve as the organization's senior subject matter expert for specialty pharmaceutical reimbursement, with particular emphasis on GLP-1 medications.
• Provide expert guidance regarding commercial insurance, Medicare, Medicaid, and applicable pharmacy and medical benefit structures.
• Interpret payer-specific reimbursement requirements, formulary restrictions, step therapy, prior authorization criteria, and coverage limitations.
• Identify reimbursement trends, payer policy changes, and emerging patient access challenges.
• Develop recommendations to improve reimbursement accuracy, processing efficiency, and successful patient access outcomes.
• Provide strategic insights to operations leadership and client stakeholders regarding reimbursement challenges and evolving industry requirements.

2. Complex Case Resolution & Technical Escalations

• Serve as the senior technical escalation resource for complex reimbursement and patient access cases.
• Support resolution of challenging prior authorizations, benefit investigations, coverage denials, appeals, and reimbursement barriers.
• Provide actionable guidance to frontline Reimbursement Analysts and operational leadership.
• Partner with prescribing providers, authorized clinical resources, and client stakeholders as appropriate to facilitate resolution of complex administrative issues.
• Identify recurring payer challenges and recommend compliant resolution pathways.
• Ensure questions requiring clinical judgment or medical necessity determinations are referred to appropriately authorized professionals.

3. Operational Excellence & Process Optimization

• Evaluate reimbursement workflows and identify opportunities to improve efficiency, accuracy, and consistency.
• Partner with Operations, Quality Assurance, and Training to develop standardized reimbursement processes.
• Support root-cause analysis of recurring processing errors, aged cases, avoidable denials, and operational inefficiencies.
• Recommend and assist with implementing scalable workflows that support program expansion.
• Provide subject matter expertise during new program launches, process transitions, and operational readiness activities.
• Support development of performance measures related to reimbursement accuracy, escalation resolution, and case processing effectiveness.

4. Analyst Development & Knowledge Enablement

• Provide advanced technical coaching and guidance to Reimbursement Analysts and designated SMEs.
• Support onboarding, nesting, continuing education, and skill development initiatives.
• Identify reimbursement knowledge gaps and collaborate with Training and Operations to develop targeted learning solutions.
• Develop and maintain payer-specific knowledge resources, technical guidance, standard operating procedures, and escalation frameworks.
• Participate in quality calibration sessions and provide specialized reimbursement expertise.
• Promote consistent application of reimbursement best practices across operational teams.

5. Client Partnership & Strategic Advisory

• Serve as a senior reimbursement subject matter resource in designated client discussions.
• Translate complex reimbursement challenges into actionable operational recommendations.
• Participate in strategic discussions regarding payer trends, reimbursement barriers, process improvements, and patient access opportunities.
• Support development of reimbursement solutions aligned with client program requirements.
• Build collaborative relationships with operational leadership, client stakeholders, quality, training, and other designated functional partners.
• Communicate industry developments and recommendations that may affect program performance or patient access.

6. Program Growth & Scalability

• Provide expert input into reimbursement operational readiness as programs expand.
• Help define technical competencies and proficiency expectations for Reimbursement Analysts and SMEs.
• Recommend knowledge management, escalation, quality, and training structures appropriate for larger reimbursement teams.
• Support consistency of reimbursement practices across multiple delivery locations.
• Identify opportunities to reduce operational complexity and improve first-time-right processing.
• Collaborate with operational leadership on sustainable development of reimbursement capabilities.

Required Qualifications

• Bachelor's degree in healthcare administration, business, pharmacy-related studies, or a related discipline, or equivalent combination of education and directly relevant experience.
• 8–10+ years of progressive experience in pharmaceutical reimbursement, patient access, specialty pharmacy, healthcare revenue cycle, or related healthcare insurance operations.
• 3+ years of Director-level experience or equivalent senior functional leadership experience involving reimbursement strategy, complex escalation management, or cross-functional patient access initiatives.
• Advanced working knowledge of benefit investigations, prior authorizations, appeals, coverage determinations, payer policy interpretation, and reimbursement workflows.
• Demonstrated experience resolving complex pharmaceutical reimbursement and patient access challenges.
• Experience providing strategic advisory support to operational leaders, client stakeholders, or senior healthcare professionals.
• Demonstrated ability to translate technical reimbursement expertise into practical operational solutions.
• Experience coaching, mentoring, or providing technical direction to reimbursement professionals.
• Strong analytical, problem-solving, communication, and stakeholder management capabilities.
• Working knowledge of HIPAA, patient confidentiality, and applicable healthcare reimbursement compliance requirements.
• Ability and willingness to remain actively engaged in detailed reimbursement workflows while providing senior-level guidance.

Preferred Qualifications

• Direct experience with GLP-1 therapies and payer requirements involving Type 2 diabetes and chronic weight management.
• Experience within pharmaceutical manufacturer patient support programs, specialty pharmacy services, patient access hubs, or reimbursement support organizations.
• Familiarity with commercial payer and government-program coverage policies.
• Experience supporting reimbursement operations in a business process outsourcing or third-party service environment.
• Experience supporting large-scale or rapidly expanding reimbursement teams.
• Familiarity with electronic prior authorization systems, payer portals, CRM platforms, and case management applications.
• Relevant pharmacy technician registration, professional certification, or specialized reimbursement credentials, where applicable.

Key Performance Indicators

1. Reimbursement Accuracy - Reduction in preventable processing and documentation errors
2. Technical Escalation Support - Timely resolution or appropriate routing of complex cases
3. Prior Authorization Effectiveness - Submission completeness and preventable error trends
4. Operational Improvement - Documented reductions in rework and recurring workflow issues
5. Knowledge Development - Improvements in analyst technical proficiency
6. Payer Policy Readiness - Timely identification and communication of applicable payer changes
7. Client Partnership - Responsiveness, technical accuracy, and effectiveness of advisory support
8. Program Scalability - Development and adoption of consistent, sustainable reimbursement practices

Performance expectations will be established jointly with operational leadership based on applicable program requirements.

Organizational Alignment & Accountability

The Director, Reimbursement Strategy & Patient Access Excellence operates as a senior functional expert within the established US Operations organizational structure.

The position provides Director-level technical expertise, strategic recommendations, and cross-functional guidance while partnering with designated operational leaders responsible for program execution.

Unless specifically delegated through the approved organizational structure, this position does not independently own:

• Direct personnel management, corrective action, or employee performance decisions.
• Operational staffing, scheduling, workforce management, or attendance administration.
• Program financial performance, budgets, or commercial commitments.
• Changes to client contracts, service requirements, or organizational reporting relationships.
• Independent clinical determinations, prescribing decisions, or overrides of payer requirements.

Operational accountability remains with designated Operations leadership. The Director serves as a senior technical partner who strengthens reimbursement capabilities, supports scalable delivery, and promotes patient access excellence.

Success Profile

The successful candidate will bring the strategic perspective of an experienced pharmaceutical reimbursement leader with the practical, hands-on expertise of an advanced Reimbursement Analyst SME.

This individual will be recognized for the ability to resolve complicated reimbursement challenges, develop people through technical guidance, advise senior stakeholders, and improve operational performance without requiring traditional departmental management responsibilities.

The ideal candidate is a seasoned reimbursement professional who enjoys applying senior-level expertise directly to solving complex patient access and operational challenges.