Senior Clinical Reimbursement Specialist

Role: Senior Clinical Reimbursement Specialist responsible for managing complex pre- and post-service appeals within a healthcare reimbursement context, primarily supporting cancer diagnostics. Key responsibilities include independently handling high-dollar and ambiguous appeals, translating payer policies into clinical justification, coordinating with providers, mentoring team members, and driving process improvements to enhance overturn rates and revenue. The role involves analyzing denial patterns, contributing to workflow and SOP development, monitoring payer policy changes, and supporting digital transformation initiatives. Qualifications: Active clinical licensure (RN, NP), bachelor’s degree in nursing, 3–5 years in healthcare reimbursement, prior experience with appeals and denials, and deep understanding of payer medical policies and claims adjudication. Preferred skills include oncology diagnostics experience, participation in process improvements, and familiarity with healthcare automation or AI tools. The position reports to team leadership, involves cross-functional collaboration, and is based remotely with no specified travel. High-value specifics: focus on reimbursement for cancer diagnostics, supporting high-value appeals, and process optimization within a growing diagnostic company.