Senior Manager, Upstream Reimbursement Strategy

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Primary Function of Position The Upstream Reimbursement Strategist is the architect of the organization’s long-range reimbursement and market access strategy across the U.S. product portfolio. This person is responsible for generating all strategies for all upstream programs and dovetailing those strategies with global market access for ex-U.S. projects. This role is the closest link to the clinical development team and serves as the primary strategic interface with HEOR, regulatory affairs, and health policy stakeholders. Responsible for evidence generation strategy, CPT/HCPCS code pathway design, CMS payment policy analysis, and the global coordination of evidence that feeds both upstream regulatory submissions and downstream field execution tools. This person shapes the narrative for why a product deserves reimbursement and builds the data package to support it. This role carries shared responsibility for midstream activities (code acquisition, pre-launch payer engagement) until a dedicated Midstream hire is made (18 months). The strategic upstream work evidence, coding pathways, payment policy, is the primary focus. Responsibilities Reimbursement Evidence Strategy: Partner with HEOR to design, commission, and oversee health economic and outcomes research studies that support reimbursement across the product portfolio. Ensure evidence generation aligns with regulatory, payer, and provider needs. Reimbursement Data Collection: In coordination with HEOR, architect the evidence plans for a reimbursed product. Oversee collection of that data and packaging into publications (e.g., burden of illness, cost-utility, budget impact) for payer and provider consumption, aligned with the broader payer and provider engagement campaign. CPT/HCPCS Code Strategy: Lead the strategy for new code applications, Category III code conversions, and descriptor modifications. Manage engagement with AMA CPT Editorial Panel, RUC, and HCPCS workgroups. CMS Payment Policy Analysis: Conduct ongoing analysis of OPPS, PFS, and ASC payment policy. Prepare and submit CMS comment letters during rulemaking cycles. Monitor NT-APC, pass-through, and device payment category developments. Global Evidence Coordination: Serve as the connective tissue between U.S. evidence needs and global HEOR and OUS markets. Dovetail U.S. upstream strategies with global market access to ensure alignment on ex-U.S. projects. Ensure evidence generation is sequenced to serve both U.S. regulatory/payer needs and ex-U.S. HTA submissions, coordinating timing and deliverables across jurisdictions. Coverage Reimbursement Strategy: Generate and own the reimbursement strategy for all upstream programs across the full product portfolio. Develop and maintain the strategic reimbursement roadmap from early pipeline through commercialization, including target product profiles (TPPs) and core value dossiers (CVDs) for pipeline assets. Identify coverage gaps, analyze competitive reimbursement positioning, recommend pathway strategies, and ensure strategic continuity as products progress through development milestones. U.S. Value Plan Implementation Support: Play a supporting role to HEOR in ensuring the U.S. Market Access team has secured the database resources required to execute strategy and implement the recommendations set out in the U.S. Value Plan. Competitive Intelligence: Monitor competitor reimbursement strategies, code applications, pass-through approvals, and coverage determinations. Translate competitive intelligence into actionable strategic recommendations. Product Positioning Message Alignment: Serve as the primary owner of product positioning in coordination with select downstream stakeholders, ensuring messaging is consistent across other stakeholders in the organization ,particularly when producing publications such as burden of illness, cost-utility, and budget impact analyses. Stakeholder Interface: Serve as the primary reimbursement strategy interface with clinical development

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