The Position:

We are seeking an experienced Senior Clinical Reimbursement Specialist to serve as a clinical subject matter expert on our Clinical Reimbursement Operations team. In this role, you will independently manage complex pre- and post-service appeals, mentor junior team members, and drive process improvements that measurably improve overturn rates and revenue capture across the revenue cycle.

You will apply advanced clinical judgment and deep payer policy expertise to handle the team's most complex, high-dollar, and precedent-setting cases - including Level 2 appeals, external reviews, and payer escalations. Beyond individual casework, you will contribute to workflow design, SOP development, and cross-functional initiatives that strengthen the team's overall performance.

Success in this role requires advanced knowledge of reimbursement systems (including payer utilization management and claims adjudication), fluency in payer medical policies, sound and independent clinical judgment on complex cases, and the ability to influence outcomes through both direct case ownership and informal leadership.

Primary Duties and Responsibilities

• Independently manage complex pre- and post-service appeals across Level 1, Level 2, and external review pathways, including the review, development, and submission of clinically robust appeal documentation.
• Serve as a clinical subject matter expert on payer medical policies, translating complex policy criteria into patient-specific clinical justification and guiding appeal strategy for high-dollar, ambiguous, or precedent-setting cases.
• Own end-to-end resolution of assigned cases, including follow-up, coordination with ordering providers, and appropriate escalation to leadership when warranted.
• Partner with ordering physicians and practice staff to coordinate peer-to-peer reviews, gather supplemental clinical documentation, secure Authorized Representative forms and signatures, and support collaborative initiatives that strengthen appeal outcomes.
• Mentor and provide informal guidance to Clinical Reimbursement Specialists, including case review, appeal letter quality feedback, and coaching on payer policy interpretation.
• Lead analysis of denial patterns and appeal outcomes to identify root causes, and drive upstream feedback to reduce future denials.
• Contribute directly to the development and refinement of appeal letter templates, clinical evidence packets, payer reference guides, and other scalable operational tools.
• Monitor payer behavior and policy changes across all lines of business; flag material changes and partner with leadership on remediations, coverage reviews, and payer escalations.
• Support the maintenance and continuous improvement of SOPs, ensuring workflows remain consistent, compliant, and scalable as the team grows.
• Serve as point of contact for complex patient- or provider-facing inquiries, ensuring accurate, empathetic, and compliant communication.
• Support digital transformation initiatives, including automation and AI/agentic workflow pilots that improve appeal readiness scoring and clinical documentation review.
• Represent the Clinical Reimbursement team in cross-functional initiatives and special projects that support evolving reimbursement and operational priorities.

Who You Are:

Qualifications

Required

• 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.
• Demonstrated ability to independently manage complex, ambiguous, or high-dollar cases without routine escalation.
• Proven ability to translate complex payer medical policy criteria into patient-specific clinical justification.
• Strong critical thinking and analytical skills, including the ability to interpret incomplete denial information and drive appropriate next steps without direction.
• Experience contributing to the development of SOPs, appeal letter templates, workflow tools, or other operational assets within a reimbursement environment.
• Demonstrated ability to mentor or provide informal leadership to peers, including case review, coaching, or SME support.
• Excellent communication and collaboration skills, with the ability to influence cross-functional discussions and convey clinical/reimbursement concepts to both clinical and non-clinical stakeholders.
• Demonstrates ownership of cases through resolution, including follow-up, coordination, and appropriate escalation.
• Comfortable working in an evolving environment with shifting priorities, ambiguity, and the need to build systems where none exist.

Preferred

• Prior experience in oncology diagnostics, laboratory services, or complex/specialty reimbursement environments.
• Experience leading or contributing to process improvement, workflow redesign, or operational scaling initiatives within the revenue cycle.
• Familiarity with digital transformation initiatives in healthcare operations (automation, AI/agentic workflows, workflow tools, system integration).
• Relevant certification (CPC, CRCR, CHFP, Lean/Six Sigma) or Master's degree (MSN, MHA, MBA).

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