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Position Overview

The Sr Appeals Specialist will be responsible for designing and implementing an appeal strategy to optimize reimbursement success and reduce claim denials. Reporting to the Senior Manager of Reimbursement Operations, this individual contributor role focuses on enhancing the appeals process, from identifying root causes of denials to creating workflows and templates that increase successful appeals. This role will collaborate closely with the payor relations team as well as of the rest of reimbursement operations and external vendors to ensure consistent, compliant, and effective appeals handling across the organization.

Key Responsibilities and Essential Functions

Develop and implement an appeals strategy that reduces denial rates and improves reimbursement outcomes. Conduct thorough root-cause analysis of denied claims, identifying patterns and developing strategies to address systemic issues. Create, maintain, and optimize appeal templates, documentation standards, and workflows to streamline the appeals process. Work cross-functionally with billing, prior authorization, and insurance verification teams to coordinate efforts and enhance appeals effectiveness. Monitor regulatory changes and payer policies, ensuring appeal practices remain compliant and adjusting strategies as needed. Track, analyze, and report on appeal outcomes, providing insights to management to support continuous improvement in reimbursement processes. Establish key performance indicators (KPIs) for appeal effectiveness and develop data-driven recommendations for ongoing optimization. Serve as the subject matter expert on appeal processes, providing guidance, training, and support to reimbursement operations staff. Collaborate with IT and analytics teams to develop tools and dashboards that facilitate tracking and reporting on appeal metrics. In coordination with the Payor Relations team engage with payers, as necessary, to resolve high-priority appeals and maintain productive relationships that support favorable outcomes.

Position Requirements (Education, Experience, Other)

Required

Bachelor’s degree + 5 years of experience in healthcare and/or life sciences 5+ years of experience in healthcare reimbursement, with a focus on claims appeals, denials management, or related areas. In-depth knowledge of medical billing and coding standards, including ICD-10, CPT, and payer guidelines. Demonstrated experience in developing appeal strategies or processes in a healthcare setting. Strong analytical skills, with the ability to identify trends and develop actionable strategies based on data. Excellent written and verbal communication skills for effectively communicating with internal stakeholders and payers. Detail-oriented and highly organized, with a proactive approach to managing complex appeal cases. Ability to work collaboratively in a cross-functional environment Experience with revenue cycle management in a CLIA-certified laboratory or similar healthcare setting. Familiarity with healthcare software solutions and data visualization tools, such as Tableau or Power BI. Knowledge of payer policies, reimbursement regulations, and healthcare compliance standards. Proven ability to work independently, manage multiple tasks, and prioritize in a fast-paced environment.

#LI-Remote

Compensation

Salary Range: $79,400 - $119,200

Other compensation elements include:

equity grant bonus eligible

ALERT: Malicious groups posing as Adaptive employees have recently used fraudulent email aliases to extend employment offers, provide fake documents, and request sensitive personal and financial information. Legitimate Adaptive employment opportunities are initiated through our careers page and extended after multiple interviews with verified employees. Adaptive does not ask new hires to purchase anything out-of-pocket, including home office supplies and equipment. 

Interested in this position, but don’t meet all the requirements?  Adaptive is committed to building diverse, equitable, and inclusive teams across our organization.  Please consider applying even if your experience doesn’t match all the qualifications; you may be the exact candidate we’re searching for!

Adaptive is not currently sponsoring candidates requiring work authorization support for this position.

Adaptive’s posted compensation information includes a base salary (or hourly rate) range and summary of other available total compensation. The base salary range represents a minimum-to-maximum salary (or hourly rate) available to candidates upon extension of offer. Base salary is thoughtfully considered upon offer and is determined through multiple evaluation checks throughout the interview process, including: a candidate’s ability to meet minimum qualifications (skills/experience/education), a candidate’s ability to thoughtfully address preferred qualifications, current market conditions, and internal pay equity. Listed base salary is exclusive of bonus, commission, equity, differential pay, benefits, and other incentives.

Adaptive's benefits at-a-glance.

Adaptive Biotechnologies is an Affirmative Action and Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability. Please refer the Equal Employment Opportunity Posters for more information. If you’d like to view a copy of the company’s affirmative action plan or policy statement, please email hr@adaptivebiotech.com.

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NOTE TO EMPLOYMENT AGENCIES: Adaptive Biotechnologies values our relationships with our Recruitment Partners and will only accept resumes from those partners who have active agreements with Adaptive. Adaptive Biotechnologies is not responsible for any fees related to resumes that are unsolicited or are received by any employee of Adaptive Biotechnologies who is not a member of the Human Resources team.