Senior Manager, Reimbursement Operations

Position Overview

The Senior Manager, Reimbursement Operations will lead the reimbursement operations team in managing all front-end and prior authorization processes, as well as other reimbursement operations functions such as insurance eligibility/discovery, client billing, post-claim follow-up and account outreach. This role will oversee and enhance workflows to maximize reimbursement, minimize denials, and streamline communication with both internal and external stakeholders. The Senior Manager will collaborate closely with cross-functional teams such as the Payor Relations team and play a pivotal role in refining and implementing strategic improvements within reimbursement operations. Successful candidates will demonstrate leadership skills, attention to detail, and the ability to drive outcomes in a dynamic healthcare environment.

Leaders at Adaptive demonstrate behaviors consistent with Adaptive’s Core Values and Leadership Principles. Critical functions of your role include helping establish individual team member goals, aligning those individual goals with broader team objectives, and ensuring those objectives drive the achievement of company goals. Providing thoughtful coaching and consistent feedback to your team members will drive performance excellence and accountability, as well as support your team members’ growth and development. Leaders at Adaptive create an environment of belonging, respect, and open and honest communication every day.

Key Responsibilities and Essential Functions

• Lead and oversee the Prior Authorization, Eligibility, and Insurance Discovery teams, ensuring timely and accurate processing of authorizations.
• Ensure comprehensive insurance eligibility and benefit discovery processes for new and existing patients.
• Develop and implement strategies to improve prior authorization approval rates and reduce denials.
• Manage the account outreach team to ensure accurate and timely medical record collection for billing and reimbursement.
• Oversee client billing processes, ensuring compliance and accuracy in all billing activities.
• Develop and monitor processes for Letters of Agreement (LOAs) to align with reimbursement requirements.
• Manage appeals and claims follow-up processes, ensuring compliance with all regulatory standards and maximizing successful appeals.
• Collaborate with the analytics team to create reports and dashboards that track reimbursement and authorization metrics.
• Provide training, guidance, and coaching to team members to foster skill development and compliance with policies.
• Identify and implement process improvements to streamline reimbursement workflows and reduce administrative burden.
• Serve as point of contact for cross-functional teams in sales, clinical services, and finance for reimbursement operations-related queries.
• Collaborate with third-party vendors to optimize software and service solutions for reimbursement operations.
• Establish clear goals for the team, align them with organizational objectives, and monitor team performance.
• Participate in forecasting and budgeting processes in collaboration with finance and other operational teams.
• Ensure compliance with all federal, state, and local laws and regulations regarding billing and reimbursement practices.

Position Requirements (Education, Experience, Other)

Required

• Bachelor’s degree, 12+ years of experience in healthcare reimbursement operations with at least 5 years in a management role preferred
• Minimum of 5 years of experience with billing and reimbursement in CLIA laboratory services sector, oncology industry preferred.
• Extensive experience with prior authorization, insurance eligibility, account outreach, billing, and appeals processes.
• Strong understanding of medical billing and coding, including knowledge of ICD-10, CPT codes, and payer guidelines.
• Experience managing and optimizing workflows and processes to improve reimbursement rates.
• Proven ability to lead and develop high-performing teams.
• Proficiency in data analysis, with a strong ability to derive insights from metrics to drive improvements.
• Strong written and verbal communication skills for effective interaction with stakeholders at all levels.
• Ability to work collaboratively in a cross-functional environment

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Compensation

Salary Range: $127,400 - $191,200

Other compensation elements include:

• equity grant
• bonus eligible