Senior Clinical Reimbursement Specialist

Veracyte, Inc.; United States; Teletrabalho; USD 86 000 - 138 000; Tempo integral

Resumo da oferta

Veracyte, Inc. is hiring a Senior Clinical Reimbursement Specialist to lead complex payer appeals and analyst work within the Clinical Reimbursement Operations team.

You will mentor junior staff, design improvements, and apply advanced clinical judgment across Level 1–External reviews to improve revenue capture. The role requires nursing licensure, a degree in nursing, and 3–5 years in reimbursement or revenue cycle roles, with strong policy interpretation and cross-functional collaboration

Qualificações

• Active clinical licensure and nursing degree required.
• 3–5 years in healthcare reimbursement or revenue cycle roles.
• 2+ years in prior authorization, denial management, or appeals.
• Strong ability to mentor peers and lead without formal authority.

Responsabilidades

• Independently manage complex pre- and post-service appeals across levels.
• Translate payer policies into patient-specific clinical justification for cases.
• Own end-to-end resolution with follow-up and escalation when needed.
• Lead development of SOPs, templates, and workflow tools.
• Monitor payer policy changes and drive remediations.

Conhecimentos

Excellent communication

Clinical reimbursement knowledge

Mentoring / SME support

Formação académica

Associate or Bachelor's degree in nursing

Active clinical licensure (RN, NP)

Ferramentas

SOP development

Workflow tools

Descrição da oferta de emprego

At the company, we offer exciting career opportunities for those interested in joining a pioneering team that is committed to transforming cancer care for patients across the globe. Working at the company enables our employees to not only make a meaningful impact on the lives of patients, but to also learn and grow within a purpose driven environment. This is what we call the the company way – it’s about how we work together, guided by our values, to give clinicians the insights they need to help patients make life-changing decisions.

Our Values:

• We Seek A Better Way: We pursue bold ideas, embrace complexity, and keep pushing forward.
• We Make It Happen: We act with urgency, deliver with excellence, and always find a way.
• We Are Stronger Together: We engage with empathy, align around what's best for the company, and celebrate as one team.
• We Care Deeply: We show up with integrity, kindness, and respect for one another.

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).

#LI-Remote

For San Diego based candidates, the salary range is $113,276 - $125,000.For South San Francisco based candidates, the salary range is $119,110 - $137,657.For candidates in other locations in the U.S., the salary range is $86,098 - $107,850.

The final salary offered to a successful candidate will be dependent on several factors that may include but are not limited to years of experience, skillset, geographic location, industry, education, etc. Base pay is one part of the Total Package that is provided to compensate and recognize employees for their work, and this role may be eligible for additional discretionary bonuses/incentives, and restricted stock units.

Pay range

$86,098—$137,657 USD

What We Can Offer Youthe company is a growing company that offers significant career opportunities if you are curious, driven, patient-oriented and aspire to help us build a great company. We offer competitive compensation and benefits, and are committed to fostering an inclusive workforce, where diverse backgrounds are represented, engaged, and empowered to drive innovative ideas and decisions. We are thrilled to be recognized as a 2024 Certified™ Great Place to Work® in both the US and Israel - a testament to our dynamic, inclusive, and inspiring workplace where passion meets purpose.

About the companythe company (Nasdaq: VCYT) is a global diagnostics company whose vision is to transform cancer care for patients all over the world. We empower clinicians with the high-value insights they need to guide and assure patients at pivotal moments in the race to diagnose and treat cancer. Our the company Diagnostics Platform delivers high-performing cancer tests that are fueled by broad genomic and clinical data, deep bioinformatic and AI capabilities, and a powerful evidence-generation engine, which ultimately drives durable reimbursement and guideline inclusion for our tests, along with new insights to support continued innovation and pipeline development. For more information, please visit www.the company.com or follow us on LinkedIn or X (Twitter).

the company, Inc. is an Equal Opportunity Employer and will consider all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability status. the company participates in E-Verify in the United States. View our CCPA Disclosure Notice