General Summary:
Vertex is currently building a field reimbursement team to support our upcoming journey to advance, develop, and deliver therapies to those living with serious kidney diseases. We are preparing for potential commercialization of investigational therapeutics being studied for the treatment of Immunoglobulin A nephropathy (IgAN), additional B cell-mediated diseases, and other genetic kidney diseases. We are seeking a dedicated and collaborative Field Reimbursement Manager to join our Kidney Patient Support Program (KPSP). In this field-based role, you will serve as the local subject matter expert to nephrology practices, providing non-promotional access and reimbursement education. You will also support timely access for patients to prescribed Vertex kidney therapies through effective troubleshooting and territory-level payer expertise.
Key Duties and Responsibilities:
- Compliantly establish strong connections with key nephrology office personnel, including members of the care team and administrative staff responsible for prior authorizations and patient access to specialty medications, to support patient access to prescribed medications.
- Partner with case management team to address escalated access issues; ensure coordinated handoffs using CRM triggers and workflows.
- Support timely patient access to their prescribed Vertex medicine by educating offices on copay, PAP, Bridge programs, and other affordability pathways.
- Provide timely follow-up on case status and ensure offices understand insurance documentation requirements.
- Maintain a comprehensive understanding of commercial and government prescription insurance coverage requirements for access and payer trends.
- Conduct on-site and virtual in-services to deliver compliant and comprehensive education on:
- Regional payer policies, formulary updates, and coverage nuances.
- PA/medical exception criteria, coding/billing (ICD‑10, CPT), and documentation requirements.
- Distribution pathways, hub services, enrollment processes, and reimbursement workflows.
- Conduct on-site and virtual training using approved payer guides, checklists, access tools, and workflow maps.
- Independently manage a multistate geographic region, prioritizing accounts based on patient need, payer dynamics, and KPSP demand.
- Adapt engagement with prescribing HCP offices based on existing office workflows and avoid introducing complexities or inefficiencies.
- Develop territory engagement plans reflecting local payer landscapes and practice resources to help minimize patient-specific access barriers
- Adhere to strict non‑promotional guidelines; all engagements must be compliant with relevant legal/compliance/privacy guardrails.
- Maintain confidentiality of patient health information and act in compliance with all laws, regulations, and Vertex company policies
- Apply program business rules and work instructions to deliver a consistent and compliant patient and customer experience.
Knowledge and Skills:
- Experience working with specialty biologics, rare disease therapies, or complex pharmacy benefit products.
- Account management experience, working directly with HCPs and office staff to navigate complex access challenges
- Ability to navigate payer portals, CRM systems, and field access tools.
- Strong communication, training, and relationship-building skills with provider office staff and internal PSP and vendor teams.
- Strong analytical skills: ability to derive insights from customer and internal team engagements
- Ability to leverage data and reporting tools to manage caseload and prioritize patient needs
- Comfortable working in a fast-paced, results-driven environment within a growing business unit
- Experience developing and executing strategic business/account plans
- Demonstrated ability to facilitate appropriate judgment in decision making and problem solving
- Ability to travel 50-70% within assigned territory.
- Proficiency in Microsoft Outlook, Word, Excel, PowerPoint, Salesforce CRM
- While the Company is usually closed on holidays, employees may be asked on occasion to work to meet organizational needs
- Valid driver's license and ability to meet safe driving requirements
- Ability to satisfy and meet all health care industry representative credentialing requirements to gain and maintain entry into facilities and organizations that are in your assigned territory
Education and Experience:
- Bachelor’s degree in health care, life sciences or business field; advanced degree in business, healthcare, social services is a plus
- Minimum 5+ years’ experience in sales, reimbursement, market access, specialty pharmacy, patient services, or field-based access roles.
- Deep understanding of benefits investigations, PA processes, appeals, coverage policies, and payer ecosystems.
- Payer knowledge and in-depth understanding of Medicare, Medicaid, and commercial insurance plans.
