Clinical Claims Appeals Manager

Caris Life Sciences•Irving, TX

1d•Hybrid

About The Position

Caris Life Sciences is seeking a clinically experienced and strategically minded Clinical Claims Appeals Manager who is a Registered Nurse (RN), preferably bachelor's prepared, with direct health insurance company experience in clinical appeals, utilization management, medical necessity review, or medical policy. This individual will develop and execute second-level appeal strategies for complex claim denials, with an emphasis on determinations that Caris testing is not medically necessary. The position will combine payer-side clinical review experience, nursing judgment, medical policy analysis, and persuasive appeal writing to improve reimbursement outcomes for Caris molecular profiling and precision oncology services. The Manager will serve as a clinical appeals subject matter expert within Revenue Cycle Management and will partner with Market Access, Clinical and Scientific Marketing, Legal, Billing Operations, and other stakeholders to convert payer denial rationales into evidence-based, payer-specific appeal approaches. The role will also identify recurring denial patterns, build scalable appeal tools, and support escalations involving health plan medical directors, external review organizations, and other applicable review channels.

Requirements

Active, unrestricted Registered Nurse (RN) license in good standing.
Bachelor of Science in Nursing (BSN) or other bachelor's degree with equivalent relevant clinical experience.
Five or more years of experience in clinical appeals, utilization management, medical necessity review, medical policy, prior authorization, provider disputes, or a related payer function.
Direct experience working for a commercial health insurance company, Medicare Advantage organization, managed care organization, or other health plan.
Two or more years of leadership, supervisory, project leadership, or demonstrated team-lead experience.
Demonstrated experience evaluating medical necessity denials and developing written clinical arguments for reconsideration or appeal.
Knowledge of payer medical policy development and application, utilization management processes, appeal rights, and external review pathways.
Exceptional clinical writing, critical thinking, analytical, organization, and verbal communication skills.
Ability to interpret complex medical records, payer correspondence, policies, guidelines, and clinical literature.
Ability to manage multiple priorities and deliver accurate work within payer filing deadlines.
Clinical judgment and the ability to connect patient-specific facts to payer coverage criteria and published evidence.
Persuasive, precise writing that directly addresses the stated basis for denial.
Ability to recognize payer review patterns and convert case-level findings into scalable strategy.
Strong collaboration skills across clinical, operational, reimbursement, compliance, and legal functions.
Comfort presenting complex clinical and reimbursement topics to operational and executive audiences.
High attention to detail, sound judgment, discretion, and commitment to ethical conduct.
Proficient in Microsoft Office Suite, specifically Word, Excel, Outlook, and general working knowledge of Internet for business use.

Nice To Haves

Oncology nursing, oncology utilization management, or oncology appeals experience.
Experience with molecular diagnostics, comprehensive genomic profiling, next-generation sequencing, precision oncology, or clinical laboratory services.
Experience communicating with payer medical directors, physician reviewers, independent review organizations, or external review entities.
Working knowledge of NCCN Clinical Practice Guidelines in Oncology, Medicare coverage requirements, MolDX processes, and commercial payer molecular diagnostic policies.
Master's degree in nursing, healthcare administration, public health, business, or a related field.
Professional certification such as Certified Case Manager (CCM), Oncology Certified Nurse (OCN), or another relevant utilization management or appeals credential.
Experience with Epic, XIFIN, or a comparable revenue cycle, claims, or clinical review platform.

Responsibilities

Initiate and facilitate payer escalations, including direct telephone outreach to health plans, laboratory benefit management (LBM) vendors, utilization management departments, and medical review teams when appeals are not routed or reviewed appropriately. Advocate for reassignment to the appropriate specialty reviewer, peer-to-peer discussion, medical director review, or other escalation pathway necessary to obtain a complete and clinically appropriate reconsideration.
Coordinate, participate in, and facilitate peer-to-peer discussions involving payer medical directors, utilization management nurses, internal pathologists, ordering physicians, and other clinical stakeholders to support medical necessity reviews, appeal escalations, and coverage reconsideration efforts.
Develop and maintain standardized appeal templates, clinical argument modules, evidence summaries, checklists, and supporting-document requirements for Caris tests and commonly denied indications.
Customize appeal narratives using patient-specific clinical facts, payer policy language, applicable guidelines, peer-reviewed literature, and available clinical evidence.
Create quality standards for second-level appeals, including clinical accuracy, completeness, consistency, timeliness, and alignment with the denial reason.
Build and govern a centralized appeal evidence library organized by payer, test, tumor type, denial category, and appeal outcome.
Ensure appeal materials accurately represent Caris services and are consistent with approved clinical, legal, compliance, and reimbursement positions.
Monitor second-level appeal volumes, overturn rates, recovery, aging, turnaround time, payer response, and denial recurrence.
Analyze outcomes by payer, denial reason, product, indication, and appeal approach to identify effective strategies and areas requiring intervention.
Provide actionable reporting and recommendations to Revenue Cycle and cross-functional leadership.
Use appeal outcomes to improve upstream processes, including order documentation, prior authorization, first-level appeals, and payer escalation strategy.
Support development of annual goals, operating plans, and performance measures for the clinical appeals function.
Lead, coach, and develop nurses, clinical appeals specialists, or other assigned team members responsible for complex appeals. Initially, the role will provide leadership through a matrix-management structure, partnering with existing appeals teams to establish clinical appeal processes, quality standards, workflows, and best practices.
Advise first-level appeal leaders and operational teams on payer-specific clinical strategies, documentation requirements, and evidence positioning to improve initial appeal success rates and reduce unnecessary escalation to subsequent appeal levels.
May eventually be responsible for designing, building, and scaling Caris' Clinical Appeals function, including development of the organizational structure, recruitment, onboarding, and leadership of a dedicated team of RN Clinical Appeals Specialists as the function matures.
Conduct case reviews and provide clinical guidance for high-risk or difficult medical necessity denials.
Establish training and competency expectations for clinical appeal review and writing.
Serve as the primary Revenue Cycle clinical resource for medical necessity appeal strategy and payer clinical review practices.
Collaborate with Market Access on systemic payer issues and policy reconsideration opportunities; with Clinical & Scientific Marketing on evidence and clinical rationale; with Legal and Compliance on regulated or disputed matters; and with Billing Operations on timely, accurate submission and tracking.
Participate in payer escalation discussions and prepare clinical appeal summaries for executive or medical director review.
Ensure appeals are submitted in accordance with payer requirements, applicable laws and regulations, Caris policies, and contractual obligations.
Maintain complete, accurate, and audit-ready records of appeal rationale, supporting evidence, correspondence, decisions, and outcomes.
Protect patient information and confidential business information in accordance with Caris privacy, security, and compliance requirements.
Escalate compliance, legal, or patient-impact concerns through appropriate Caris channels.