Senior Clinical Reimbursement Specialist

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.

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.

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.

Qualifications

• 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).

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.