Senior Clinical Reimbursement Specialist

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

📋 Description

• Take charge of intricate pre- and post-service appeals across Level 1, Level 2, and external review pathways.

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

• Act as a clinical subject matter expert regarding payer medical policies and devise appeal strategies for complex cases.

• Manage the complete resolution process for assigned cases, encompassing follow-up, provider coordination, and escalation.

• Organize peer-to-peer reviews and collect additional clinical documentation along with Authorized Representative forms and signatures.

• Guide and mentor Clinical Reimbursement Specialists informally.

• Evaluate denial trends and appeal results, pinpoint root causes, and provide feedback to minimize future denials.

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

• Observe payer behavior and policy modifications, collaborating with leadership on remediations, coverage evaluations, and payer escalations.

• Sustain and enhance Standard Operating Procedures (SOPs) for consistent, compliant, and scalable workflows.

• Address complex inquiries from patients or providers.

• Assist in automation and AI/agentic workflow pilot projects.

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

⛳️ Requirements

• Current 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.

• Over 2 years of experience in prior authorization, denial management, or appeals, covering both pre-service and post-service workflows.

• In-depth knowledge of payer medical policies, prior authorization, claims adjudication, denials, and appeals processes.

• Capability to independently manage complex, unclear, or high-dollar cases.

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

• Strong analytical and critical thinking skills.

• Experience in developing SOPs, appeal letter templates, workflow tools, or operational resources.

• Ability to mentor or provide informal leadership to colleagues.

• Excellent communication and collaboration abilities.

• Proficiency in owning cases through to resolution and effectively navigating shifting priorities and uncertainties.

• Preferred: experience in oncology diagnostics, laboratory services, specialty reimbursement, process enhancement, workflow redesign, healthcare automation/AI, or relevant certification/master's degree.

🏝️ Benefits

• Competitive compensation and benefits package.

• Potential eligibility for additional discretionary bonuses/incentives.

• Potential eligibility for restricted stock units.

• Career advancement opportunities and avenues for learning and growth.

• Commitment to an inclusive workforce and workplace.

• Recognized as a 2024 Certified Great Place to Work in the US and Israel.