Senior Clinical Reimbursement Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Efficiently oversee intricate pre- and post-service appeals across Level 1, Level 2, and external review channels.

• Assess, create, and submit clinically comprehensive appeal documentation.

• Act as a clinical subject matter expert on payer medical policies while directing appeal strategies.

• Take ownership of the complete resolution process for assigned cases, including follow-ups and escalations.

• Facilitate peer-to-peer reviews and collect additional clinical documentation in collaboration with ordering physicians and practice staff.

• Ensure collection of Authorized Representative forms and necessary signatures.

• Provide mentorship to Clinical Reimbursement Specialists through case evaluations, constructive feedback, and coaching.

• Examine denial trends and appeal results to pinpoint root causes and mitigate future denials.

• Create and enhance appeal letter templates, clinical evidence packets, payer reference guides, and operational resources.

• Track payer behaviors and policy updates, while assisting with remediations, coverage assessments, and payer escalations.

• Maintain and enhance standard operating procedures (SOPs) for reliable, compliant, and scalable workflows.

• Address complex inquiries from patients or providers.

• Aid in the implementation of automation and AI/agentic workflow pilot projects.

• Represent the Clinical Reimbursement team in cross-functional projects and special initiatives.

⛳️ 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 positions.

• 2+ years of experience in prior authorization, denial management, or appeals, encompassing both pre-service and post-service processes.

• Advanced knowledge of payer medical policies, prior authorization, claims adjudication, denials, and appeals, including Level 1, Level 2, and external review procedures.

• Capability to independently manage complex, ambiguous, or high-value cases without regular escalation.

• Proficiency in translating intricate payer medical policy criteria into patient-specific clinical justifications.

• Strong analytical and critical thinking capabilities.

• Experience in contributing to SOPs, appeal letter templates, workflow tools, or other operational resources within a reimbursement context.

• Ability to mentor or informally lead peers.

• Exceptional communication and collaboration abilities.

• Capacity to thrive in a dynamic environment with changing priorities and uncertainties.

• Preferred: experience in oncology diagnostics, laboratory services, or complex/specialty reimbursement settings.

• Preferred: experience in process improvement, workflow redesign, or operational scaling.

• Preferred: familiarity with healthcare automation, AI/agentic workflows, workflow tools, or system integrations.

• Preferred: CPC, CRCR, CHFP, Lean/Six Sigma certification, or a Master's degree.

🏝️ Benefits

• Competitive compensation and benefits package.

• Eligibility for additional discretionary bonuses/incentives.

• Restricted stock units.

• Career advancement opportunities and potential for growth.

• Inclusive workforce and workplace environment.