高级临床报销专员
Senior Clinical Reimbursement Specialist
在Veracyte，我们为那些希望加入一个致力于在全球范围内改善癌症治疗的先锋团队的人提供充满机遇的职业发展机会。在Veracyte工作，我们的员工不仅能对患者的生活产生深远影响，还能在一个以使命驱动的环境中学习和成长。这就是我们所说的Veracyte方式——它关乎我们如何在价值观的指引下协作，为临床医生提供他们需要的洞察，帮助患者做出改变生命的决定。
我们的价值观：
- 我们追求更好的方法：我们追求大胆的想法，拥抱复杂性，并不断前进。
- 我们实现目标：我们以紧迫感行动，以卓越交付，并总能找到办法。
- 我们团结一致：我们以同理心互动，围绕对Veracyte最有利的事物达成一致，并作为一个团队庆祝成功。
- 我们深怀关怀：我们以诚信、善良和尊重彼此相待。
职位描述：
我们正在寻找一位经验丰富的高级临床报销专家，作为临床报销运营团队的临床领域专家。在此职位上，您将独立处理复杂的前期和后期服务申诉，指导初级团队成员，并推动可显著提高推翻率和收入捕捉的流程改进，贯穿整个收入周期。
您将运用高级的临床判断力和深厚的付款人政策专业知识，处理团队中最复杂、高金额和具有先例意义的案件——包括二级申诉、外部审查和付款人升级。除了个人案件工作外，您还将参与流程设计、标准操作程序开发以及跨职能项目，以提升团队整体表现。
此职位的成功需要对报销系统（包括付款人使用管理及索赔裁定）有深入了解，对付款人医疗政策有流利的理解，对复杂案件有稳健且独立的临床判断力，并能够通过直接案件管理和非正式领导力影响结果。
主要职责和任务
- 独立处理各级别（一级、二级和外部审查）的前期和后期服务申诉，包括对临床有力的申诉文件进行审核、开发和提交。
- 作为付款人医疗政策的临床领域专家，将复杂的政策标准转化为针对患者的临床依据，并指导高金额案件的申诉策略。
查看英文原文
At Veracyte, 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 Veracyte 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 Veracyte 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 Veracyte, 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).
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 You
Veracyte 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 Veracyte
Veracyte (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 Veracyte 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.veracyte.com or follow us on LinkedIn or X (Twitter).
Veracyte, 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. Veracyte participates in E-Verify in the United States. View our CCPA Disclosure Notice
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Originally posted on Himalayas