Senior Clinical Reimbursement Specialist

Role: Senior Clinical Reimbursement Specialist, serving as a clinical expert within the revenue cycle team, managing complex appeals and driving process improvements. Responsibilities: independently handle high-value pre- and post-service appeals (Level 1, 2, external reviews), interpret payer medical policies, translate policy criteria into clinical justifications, coordinate with providers, mentor peers, analyze denial patterns, and support operational tools and SOPs. Contribute to digital transformation initiatives and cross-functional projects. Qualifications: active clinical licensure (e.g., RN, NP), associate or bachelor's degree in nursing, 3–5 years in healthcare reimbursement or revenue cycle roles, with 2+ years in denial management and appeals. Expertise in payer policies, claims adjudication, and managing complex cases independently is essential. Preferred: experience in oncology diagnostics or specialty reimbursement, process improvement, and familiarity with healthcare automation/AI tools; certifications such as CPC, CRCR, or Lean/Six Sigma are advantageous. HighValue: focus on healthcare reimbursement, appeals, denials, payer policies, and clinical documentation within a diagnostics or cancer care context. Work setup: not specified.