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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive expertise in specialty pharmaceutical reimbursement, particularly with GLP-1 medications, and excels in resolving complex prior authorizations and reimbursement challenges. Proven ability to provide strategic guidance and improve operational efficiencies in patient access and reimbursement workflows.
Highest-signal resume keywords
Pharmaceutical Reimbursement ExpertisePrior Authorization ManagementPatient Access StrategyStakeholder ManagementHealthcare Compliance Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Benefit InvestigationsReimbursement WorkflowsComplex Escalation ManagementPayer Policy InterpretationReimbursement Strategy DevelopmentData AnalysisOperational Efficiency ImprovementTechnical CoachingQuality CalibrationRoot-Cause Analysis
Soft Skills
Analytical Problem-SolvingCommunication SkillsMentoringCollaborationLeadership
Tools & Technologies
Electronic Prior Authorization SystemsPayer PortalsCRM PlatformsCase Management Applications
Certifications & Qualifications
Pharmacy Technician RegistrationProfessional CertificationSpecialized Reimbursement Credentials
Industry Keywords
GLP-1 MedicationsMedicareMedicaidPharmacy BenefitsHealthcare Revenue CycleSpecialty PharmacyPatient Support ProgramsReimbursement Support OrganizationsCommercial Payer PoliciesGovernment-Program Coverage Policies
About the role
Key responsibilities & impact- Serve as the senior subject matter expert for specialty pharmaceutical reimbursement, with emphasis on GLP-1 medications
- Provide guidance on commercial insurance, Medicare, Medicaid, pharmacy benefits, and medical benefit structures
- Interpret payer requirements, formulary restrictions, step therapy, prior authorization criteria, and coverage limitations
- Identify reimbursement trends, payer policy changes, and patient access challenges
- Develop recommendations to improve reimbursement accuracy, processing efficiency, and patient access outcomes
- Resolve complex prior authorizations, benefit investigations, coverage denials, appeals, and reimbursement barriers
- Guide Reimbursement Analysts and operational leadership on technical escalations
- Partner with prescribing providers, authorized clinical resources, and client stakeholders
- Evaluate workflows and recommend improvements to efficiency, accuracy, consistency, and scalability
- Support root-cause analysis of processing errors, aged cases, avoidable denials, and operational inefficiencies
- Provide technical coaching, onboarding support, continuing education, and skill development for Reimbursement Analysts and SMEs
- Develop payer-specific knowledge resources, technical guidance, standard operating procedures, and escalation frameworks
- Participate in quality calibration sessions
- Advise clients and senior stakeholders on payer trends, reimbursement barriers, process improvements, and patient access opportunities
- Support program launches, process transitions, operational readiness, and program scalability
- Help define technical competencies and proficiency expectations for analysts and SMEs
- Support consistent reimbursement practices across multiple delivery locations
- Collaborate with Operations, Quality Assurance, Training, client stakeholders, and other functional partners
Requirements
What you’ll need- 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: Direct experience with GLP-1 therapies and payer requirements involving Type 2 diabetes and chronic weight management
- Preferred: Experience within pharmaceutical manufacturer patient support programs, specialty pharmacy services, patient access hubs, or reimbursement support organizations
- Preferred: Familiarity with commercial payer and government-program coverage policies
- Preferred: Experience supporting reimbursement operations in a business process outsourcing or third-party service environment
- Preferred: Experience supporting large-scale or rapidly expanding reimbursement teams
- Preferred: Familiarity with electronic prior authorization systems, payer portals, CRM platforms, and case management applications
- Preferred: Relevant pharmacy technician registration, professional certification, or specialized reimbursement credentials, where applicable
Benefits
Comp & perks- Full-time employment
- Remote work within Kentucky, Tennessee, or Virginia