Reimbursement Specialist, Appeals

Reimbursement Specialist, Appeals

Belay Diagnostics is an innovative, clinical lab working to transform the diagnosis and treatment of brain and spinal cord tumors. Our mission is to serve patients and those who care for them. Utilizing next-generation sequencing (NGS), our cerebrospinal fluid (CSF) testing platform detects arm level chromosomal alterations and mutations, enabling diagnostic insights to help guide clinical decisions. At Belay, we are growing rapidly, having recently launched our first product. Join a passionate, fast-paced team dedicated to reshaping cancer diagnostics. This is an exciting opportunity to be part of a mission-driven company with ample room for career growth and advancement.

All applicants must be legally authorized to work in the U.S.

Employment Type: Full-time

Compensation: Base Salary $70k-$85k Annually

Job Location: Onsite/Hybrid - Chicago, IL Expected 4 days in office per week

The Role

The Reimbursement Specialist, Appeals is responsible for managing and overturning insurance denials related to Belay's laboratory tests. This role requires deep familiarity with medical necessity standards, payer coverage policies, MolDX, and clinical documentation requirements for molecular and genetic diagnostics. The specialist prepares, submits, and tracks multi-level appeals to ensure appropriate reimbursement while maintaining full compliance with HIPAA and applicable regulatory requirements.

Qualifications

Education:

• Bachelor's degree in Health Information Management, Healthcare Administration, Life Sciences, or a related field.

Experience:

• 35 years of experience in medical billing, insurance appeals, or revenue cycle management.
• Demonstrated experience with laboratory billing, preferably in genetic and molecular diagnostics.
• Proven track record overturning medical necessity or investigational denials.
• Professional certification: Certified Professional Biller (CPB), Certified Revenue Cycle Specialist (CRCS), Certified Coding Specialist (CCS), or CPC.

Preferred Qualifications

• Experience working in a clinical or commercial laboratory environment.
• Knowledge of MolDX program requirements and major commercial payer laboratory testing policies.
• Familiarity with payer portal tools such as Availity or equivalent platforms.

Responsibilities

Appeals and Denial Management:

• Identify root causes of denials including medical necessity, experimental/investigational designations, incorrect coding, and insufficient documentation.
• Prepare and submit first-level, second-level, and external appeals in accordance with payer-specific timelines and requirements.
• Monitor and track appeal status across payer portals and billing systems, ensuring timely follow-up and resolution.
• Interpret and apply current healthcare regulations, payer policies, and coding guidelines throughout the appeals process.
• Engage with external counsel or third-party appeal vendors as needed for complex or escalated cases.
• Participate in legal or administrative proceedings related to appeals, providing testimony or documentation as required.

Clinical and Coding Collaboration:

• Collaborate cross-functionally with RCM, clinical, and commercial teams to obtain strong clinical narratives and supporting medical records.
• Interpret laboratory test reports and understand test indications, methodologies, and result implications as they relate to payer coverage policies.
• Work with ordering providers and clinical staff to close documentation gaps that contribute to denials.

Payer Policy and Regulatory Expertise:

• Maintain current knowledge of commercial, Medicare, and Medicaid payer policies related to molecular and genetic testing, including MolDX-administered tests.
• Analyze Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), and commercial payer medical policies.
• Apply understanding of clinical guidelines (e.g., NCCN, ACMG) to build and strengthen appeal arguments.
• Navigate payer portals including Availity and payer-specific platforms to submit, track, and resolve claims.

Tracking, Reporting, and Compliance:

• Track appeal submissions, outcomes, and reimbursement trends using billing and RCM systems.
• Maintain accurate documentation for audit readiness and compliance with HIPAA and laboratory regulatory standards.
• Identify denial patterns and provide structured feedback to billing, coding, and ordering providers to reduce future denials.
• Contribute data and insights to RCM reporting and leadership reviews.

Knowledge, Skills, and Abilities:

• Strong understanding of laboratory testing workflows, terminology, and clinical use cases in molecular diagnostics.
• Excellent written communication skills with the ability to craft persuasive, clinically grounded appeal letters.
• Advanced analytical skills to interpret denial rationales and payer policies.
• Comfortable working in a fast-paced, growth-stage environment with evolving processes and systems.
• Highly organized, detail-oriented, and able to manage multiple priorities and deadlines simultaneously.

Belay Diagnostics offers excellent health benefits (Medical, Dental, Vision, Life, and Long-Term Disability) and a 401(k) program. Belay is a team of dedicated and collaborative employees committed to improving healthcare.

Belay Diagnostics is proud to be an equal opportunity workplace. All aspects of employment decisions will be based on merit, competence, performance, and business needs. We do not discriminate on the basis of any status protected under federal, state, or local law. We celebrate diversity and are committed to creating an inclusive environment for our colleagues.