Senior Clinical Reimbursement Specialist

Responsibilities

• Independently manage complex pre- and post-service appeals across Level 1, Level 2, and external review pathways
• Serve as a clinical subject matter expert on payer medical policies and translate criteria into clinical justification
• Own end-to-end resolution of assigned cases, including coordination with ordering providers
• Partner with physicians to coordinate peer-to-peer reviews and gather supplemental documentation
• Mentor and provide informal guidance to Clinical Reimbursement Specialists
• Lead analysis of denial patterns to identify root causes and drive upstream feedback
• Contribute to the development of appeal letter templates, clinical evidence packets, and payer reference guides
• Monitor payer behavior and policy changes to flag material changes for leadership
• Support the maintenance and continuous improvement of SOPs
• Support digital transformation initiatives, including automation and AI/agentic workflow pilots

Requirements

• Active clinical licensure (e.g., RN, NP)
• Associate or Bachelor's degree in nursing
• 3–5 years of experience in healthcare reimbursement or revenue cycle operations
• 2+ years of experience in prior authorization, denial management, or appeals
• Advanced understanding of payer medical policies and claims adjudication
• Proven ability to translate complex medical policy into patient-specific clinical justification
• Strong critical thinking and analytical skills
• Experience contributing to the development of SOPs or workflow tools
• Demonstrated ability to mentor or provide informal leadership to peers

Preferred Qualifications

• Prior experience in oncology diagnostics or laboratory services
• Experience leading process improvement or workflow redesign initiatives
• Familiarity with digital transformation in healthcare (automation, AI/agentic workflows)
• Relevant certification (CPC, CRCR, CHFP, Lean/Six Sigma) or Master's degree (MSN, MHA, MBA)

About the Company

Veracyte is a global diagnostics company whose vision is to transform cancer care for patients all over the world. We empower clinicians with high-value insights to guide and assure patients at pivotal moments in the race to diagnose and treat cancer.