Senior Clinical Reimbursement Specialist
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Job Description
Senior Clinical Reimbursement Specialist managing complex payer appeals and reimbursement operations. Supporting Veracyte’s cancer diagnostics through clinical expertise, process improvement, and denial reduction.
Responsibilities:
- Independently manage complex pre- and post-service appeals across Level 1, Level 2, and external review pathways
- Review, develop, and submit clinically robust appeal documentation
- Serve as a clinical subject matter expert on payer medical policies and guide appeal strategy
- Own end-to-end resolution of assigned cases, including follow-up and escalation
- Coordinate peer-to-peer reviews and gather supplemental clinical documentation with ordering physicians and practice staff
- Secure Authorized Representative forms and signatures
- Mentor Clinical Reimbursement Specialists through case review, feedback, and coaching
- Analyze denial patterns and appeal outcomes to identify root causes and reduce future denials
- Develop and refine appeal letter templates, clinical evidence packets, payer reference guides, and operational tools
- Monitor payer behavior and policy changes and support remediations, coverage reviews, and payer escalations
- Maintain and improve SOPs for consistent, compliant, and scalable workflows
- Handle complex patient- or provider-facing inquiries
- Support automation and AI/agentic workflow pilots
- Represent the Clinical Reimbursement team in cross-functional initiatives and special projects
Requirements:
- Active clinical licensure (e.g., RN, NP)
- Associate or Bachelor's degree in nursing
- 3–5 years of experience in healthcare reimbursement, revenue cycle operations, or payer-facing roles
- 2+ years of experience in prior authorization, denial management, or appeals, including pre-service and post-service workflows
- Advanced understanding of payer medical policies, prior authorization, claims adjudication, denials, and appeals, including Level 1, Level 2, and external review processes
- Ability to independently manage complex, ambiguous, or high-dollar cases without routine escalation
- Ability to translate complex payer medical policy criteria into patient-specific clinical justification
- Strong critical thinking and analytical skills
- Experience contributing to SOPs, appeal letter templates, workflow tools, or other operational assets within a reimbursement environment
- Ability to mentor or provide informal leadership to peers
- Excellent communication and collaboration skills
- Ability to work in an evolving environment with shifting priorities and ambiguity
- Preferred: experience in oncology diagnostics, laboratory services, or complex/specialty reimbursement environments
- Preferred: process improvement, workflow redesign, or operational scaling experience
- Preferred: familiarity with healthcare automation, AI/agentic workflows, workflow tools, or system integration
- Preferred: CPC, CRCR, CHFP, Lean/Six Sigma certification or Master's degree
Benefits:
- Competitive compensation and benefits
- Eligibility for additional discretionary bonuses/incentives
- Restricted stock units
- Career opportunities and opportunities for growth
- Inclusive workforce and workplace
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