Senior Payer Relations Specialist

Role Description

The Sr Payer Relations Specialist will focus on increasing collections from insurance companies by effectively managing payor follow-up and appeals of denied claims. This position will analyze and resolve payor reimbursement issues through in-depth research and analysis of claim data, payor policies, regulations, and coverage criteria.

This position will work in collaboration with the Market Access team, other cross-functional partners and Adaptive’s revenue cycle providers to develop and implement strategies for achieving maximal reimbursement and cash recovery from commercial payors. This role will help manage the operational and administrative processes for coding, billing, and payor follow-up - including overseeing appeals, development requests, and payor projects.

Key Responsibilities and Essential Functions

• Communicate effectively with payors and internal stakeholders to resolve reimbursement issues and ensure optimal payment for Adaptive’s clinical products.
• Support revenue and ASP growth in collaboration with the Market Access team and external billing vendor.
• Stay current with payor policy changes and regulations to ensure accurate and timely reimbursement of claims.
• Provide support and guidance to clinical and administrative staff on reimbursement and compliance issues.
• Review claims and supporting clinical documents for billing and coding accuracy.
• Remain knowledgeable on third-party requirements, and regulatory guidelines at the federal, state, and local levels.
• Support reduction in denials percentage, claims underpayments and time to adjudication.
• Work with data analytics and revenue operations team to refine analytical tools that support process efficiencies and data-driven insights.
• Generate and analyze reports to identify trends, areas for improvement and potential revenue opportunities.
• Monitor and maintain accurate and up-to-date payor contract information in billing systems.
• All other duties as assigned.

Qualifications

• 5-7+ years billing, coding, and reimbursement experience in CLIA laboratory services sector - pathology and oncology industry preferred. Commensurate experience in other healthcare provider settings will be considered.
• Strong knowledge of Medicare, Medicaid, and private insurance reimbursement processes and regulations.
• Proficient knowledge of CMS guidelines.
• Excellent interpersonal and communication skills, with the ability to build and maintain positive relationships with insurance payors.
• Ability to work independently, prioritize tasks, and meet deadlines in a fast-paced environment.
• Strong problem-solving skills, with the ability to quickly identify and resolve issues affecting payment of claims.
• Knowledge of medical billing and coding practices and procedures.
• Strong computer skills, including proficiency in Microsoft Office and healthcare billing and reimbursement software.
• Proficient knowledge and understanding of use of coding modifiers.

Requirements

• CPC or equivalent certification (Preferred).
• Knowledge of GTR, GTU and PLA coding (Preferred).
• Knowledge of PAMA (Preferred).
• Proficiency in Salesforce, Tableau, EHR and revenue cycle systems (Preferred).

Compensation

• Salary Range: $80,200 - $120,400.
• Other compensation elements include equity grant and bonus eligibility.

Benefits

Adaptive's benefits at-a-glance.