Reimbursement Manager

CareDx, Inc. is a leading precision medicine solutions company focused on the discovery, development, and commercialization of clinically differentiated, high-value healthcare solutions for transplant patients and caregivers. CareDx offers products, testing services, and digital healthcare solutions along the pre- and post-transplant patient journey, and is the leading provider of genomics-based information for transplant patients.

The Revenue Cycle Management Reimbursement Manager will be responsible for providing strategic leadership, direction and management of payer claim disputes. Their primary focus will be on gathering denials, gathering supporting documentation, frequently speaking directly with payers about denials, and leading cross-functional denial prevention and resolution. The Manager will primarily lead through organizing cross-functional groups, when necessary, to resolve denials, and may have subordinate staff. The Manager will lead the cross-functional Denials Management Steering Committee. The Manager will speak weekly with payers, internal counsel and external counsel to resolve claim disputes and audits. This role requires a deep understanding of the health insurance claim appeal process and the ability to identify opportunities for denial resolution and prevention. Candidates within commuting distance of the Brisbane, California office will need to come to the office on a regular basis; remote candidates will work and collaborate from home. Travel to the Brisbane, California office may occasionally be required.

Responsibilities:

• Dispute and Audit Management:
  • Receive and respond to payer audit and recoupment requests.
  • Successfully challenge erroneous recoupment requests by speaking with payer auditors, claim managers and others at the payer to build understanding about CareDx's tests and billing practices.
  • Escalate disputes to internal and external legal counsel to support direct payer work when needed.
  • Efficiently track and lead timely work with internal stakeholders and clinics to obtain patient medical records to support the medical necessity of patient tests billed to payers.
  • When needed, perform analysis and detailed review of payer letters, CareDx claims, and clinic test orders and medical records.
• Denials Management Steering Committee
  • Lead a regular, cross-functional meeting to resolve and prevent claim denials and disputes.
  • Monitor key performance indicators (KPIs) for changes in denial patterns, investigate specific payers patterns, and find root causes and solutions for denials.
  • Engage the cross-functional team members in between Committee meetings to complete projects and other work to successfully turn denials into payments.
  • After denials are resolved, ensure the progress is sustainable by continuing to monitor KPIs and collaborate with the Revenue Cycle Management leadership team and staff.
• Compliance and Risk Management:
  • Ensure compliance with applicable regulations, billing guidelines, and industry standards.
  • Conduct regular audits and reviews to identify compliance risks and implement corrective actions as needed.
  • Stay up to date with industry trends, regulatory changes, and reimbursement methodologies, and implement necessary adjustments to maintain compliance.
  • Assist with month-end and SOX control reporting.
  • Other duties as assigned

Qualifications:

• Bachelors degree preferred or related years of experience.
• Minimum of 8 years of experience in revenue cycle management systems & technologies, or similar experience leading the appeal process at a health insurance payer.
• At least 3 years in a people manager role.
• Extensive knowledge of healthcare billing, coding, and reimbursement practices, including government and commercial payers; experience within the diagnostics industry is preferred.
• Technical depth in at least one of the following areas:
• Denials and appeals, including Qualified Independent Contractor (QIC) and Administrative Law Judge (ALJ) appeals.
• Audit experience, including Program Integrity (UPIC or ZPIC) or Special Investigation Unit (SIU) experience.
• Project Management certification and experience, such as Scrum Master or Project Management Professional (PMP.)
• Proven track record of successfully leading cross-functional teams, driving performance & internal initiatives, and achieving goals.
• Excellent communication and interpersonal skills, with the ability to effectively collaborate cross-functionally with internal teams, external stakeholders and senior leadership.
• Ability to work in a fast-paced environment, navigating ambiguity while balancing multiple priorities.
• Experience with Telcor, Xifin or Quadex systems preferred.

Additional Details:

Every individual at CareDx has a direct impact on our collective mission to improve the lives of organ transplant patients worldwide. We believe in taking great care of our people, so they take even greater care of our patients.

Our competitive Total Rewards package includes:

• Competitive base salary and incentive compensation
• Health and welfare benefits including a gym reimbursement program
• 401(k) savings plan match
• Employee Stock Purchase Plan
• Pre-tax commuter benefits
• And more!

In addition, we have a Living Donor Employee Recovery Policy that allows up to 30 days of paid leave annually to a full-time employee who makes the selfless act of donating an organ or bone marrow.

With products that are making a difference in the lives of transplant patients today and a promising pipeline for the future, it's an exciting time to be part of the CareDx team. Join us in partnering with transplant patients to transform our future together.

CareDx, Inc. is an Equal Opportunity Employer and participates in the E-Verify program.

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