JOB SUMMARY

The Payor Reimbursement Administrator is responsible for navigating and securing reimbursement for gene therapy and oncology patients within the health system. This role ensures patients receive timely access to advanced therapies by removing reimbursement barriers, collaborating with payors, and supporting both patients and internal teams throughout the claims and payment process. The administrator acts as a liaison between patients, payors, and internal stakeholders to optimize funding and ensure claims are paid in full.

 

EDUCATION & EXPERIENCE

Minimum Qualifications:

• Bachelor’s degree in healthcare administration, business, or related field.

• Five (5) years of experience in healthcare reimbursement and patient financial assistance.

• An equivalent combination of education and experience relevant to the role may be considered for this position.

 

Preferred Qualifications:

• Demonstrated expertise experience in patient assistance specific to oncology and gene therapy.

• Experience supporting unique or specialized contract areas, such as nephrology.

 

LICENSES, REGISTRATIONS OR CERTIFICATIONS

Preferred:

• Certification in healthcare reimbursement, healthcare insurance license, or coding.

 

ESSENTIAL JOB FUNCTIONS

-Patient Advocacy & Support:

• Works directly with gene therapy and oncology patients to educate them on coverage options, financial assistance programs, and payor requirements.

• Guide patients through the reimbursement process, including prior authorizations, appeals, and documentation needs.

• Serve as the primary contact for patient reimbursement questions and concerns.

 

-Claims & Reimbursement Management:

• Works directly with Revenue Cycle Operations to ensure timely and accurate claim submission for gene therapy and oncology services, ensuring all payor requirements and documentation are met.

• Monitor claims status, follows up with payors, and resolves denials or underpayments through appeals and additional documentation.

• Analyze payments received to ensure accuracy relative to payor contracts and fee schedules. reconcile discrepancies and initiate corrections as needed.

 

-Internal Collaboration:

• Work closely with clinical, billing, revenue cycle, and pharmacy teams to ensure all reimbursement obstacles are identified and addressed proactively.

• Provide education and updates to internal staff on payor policy changes, reimbursement trends, and best practices for gene therapy and oncology claims.

• Participate in cross-functional meetings to discuss complex cases and develop solutions for reimbursement challenges.

 

-Payor Relations & Policy Navigation:

• Develop and maintain relationships with payor representatives to facilitate claim resolution and advocate for patient access.

• Stay current on payor policies, coding requirements, and reimbursement trends for gene therapy and oncology treatments.

 

JOB DESCRIPTION

• Communicate policy changes and reimbursement updates to internal teams and patients as appropriate.

-Compliance & Documentation:

• Ensure all activities comply with federal and state regulations, payor guidelines, and internal policies, including HIPAA.

• Maintain accurate and thorough documentation of all actions taken, communications, and outcomes related to reimbursement activities.

• Adheres to internal controls and reporting structure.

• Performs related duties as required.

 

KNOWLEDGE/SKILLS/ABILITIES

• Expertise in payor reimbursement processes for high-cost, innovative therapies.

• Patient-centered approach with strong advocacy skills.

• Analytical mindset for resolving complex claims and payment issues.

• Ability to educate and influence both internal and external stakeholders.

• Strong knowledge of healthcare insurance, payor policies, prior authorization, appeals, and claims management for complex therapies.

• Excellent communication, negotiation, and problem-solving skills.

• Ability to work collaboratively across multidisciplinary teams and with patients from diverse backgrounds.

• Proficiency in healthcare insurance, electronic health records, and Microsoft Office Suite.

 

WORKING ENVIRONMENT/EQUIPMENT

Remote working environment with occasional patient-facing and payor-facing meetings. Periodic office meetings will occur in Galveston/Houston

 

Salary Range:

Actual salary commensurate with experience or range if discussed and approved by the hiring authority.

 

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.

Compensation