Senior Clinical Reimbursement Specialist
Core
Senior Clinical Reimbursement Specialist managing complex pre- and post-service appeals, payer escalations, and denial management for oncology diagnostics.
Role type
Senior IC clinical reimbursement specialist
Builds
Revenue capture and overturn rates for high-dollar cancer diagnostic cases
Domain
Healthcare diagnostics / Oncology / Payer Reimbursement
Required skills
Active clinical licensure (RN/NP), Associate or Bachelor's degree in nursing, Payer policy expertise, Claims adjudication knowledge, Level 1/2/External review processes, Denial management, Peer-to-peer review coordination, SOP development, Mentorship
Preferred skills
Oncology diagnostics experience, Process improvement leadership, Digital transformation/AI workflow familiarity, CPC/CRCR/CHFP certification, Master's degree (MSN/MHA/MBA)
Technologies
None explicitly stated
Responsibilities
Manage complex pre- and post-service appeals and payer escalations; Serve as SME on payer medical policies; Own end-to-end case resolution; Mentor junior specialists; Lead denial pattern analysis; Develop appeal templates and operational tools; Monitor payer policy changes; Support digital transformation initiatives.
Seniority
Senior, hands-on IC with mentorship responsibilities