Director Clinical Operations & Coding

Baylor Genetics

1d•Remote

About The Position

The Director, Clinical Operations and Coding is responsible for ensuring clinical and coding accuracy, payer alignment, and operational rigor across CPT and ICD 10 coding review, proactive audits, medical necessity reviews, prior authorizations, and appeals for Baylor Genetics testing services. This leader partners cross functionally with Revenue Cycle, Market Access, Clinical teams, and Operations to translate payer clinical policies into scalable workflows, standardized templates, and measurable improvements in authorization and denial performance. This role may evolve as organizational needs change. What this role exists to do: Improve reimbursement outcomes by strengthening clinical defensibility and coding integrity across PA and appeals. Who it impacts: Patients, providers, client services teams, Market Access, and Revenue Cycle operations. What success looks like: Higher PA approval rates, improved appeal overturn performance, and reduced clinical denials driven by consistent, payer-aligned documentation and coding practices. Baylor Genetics’ mission is to empower patients, healthcare providers, and partners with trusted insights by translating scientific innovations into accessible clinical solutions. This role supports that mission by reducing administrative friction that delays access to testing and appropriate coverage.

Requirements

Bachelor’s degree in Nursing, Health Sciences, Healthcare Administration, Public Health, or a related field, or an equivalent combination of education and experience.
7+ years of experience in one or more of the following: revenue cycle, clinical operations, medical necessity review, utilization management, prior authorization/appeals, or coding oversight in a healthcare or laboratory environment.
Demonstrated expertise in CPT and ICD-10 coding review and audit practices; experience working with payer medical policies and coverage criteria.
Proven ability to build standardized documentation/templates and operationalize them across teams (training, governance, adoption measurement).
Strong analytical, writing, and communication skills with the ability to translate complex payer policy into clear operational guidance.

Nice To Haves

Experience in diagnostic laboratory, genetics, molecular diagnostics, or precision medicine.
Active professional certification such as CPC, CCS, RHIA/RHIT, RN, or equivalent (as applicable to candidate background).
Demonstrated experience partnering with Market Access or payer contracting teams on payer policy interpretation and denial trend mitigation.

Responsibilities

Lead CPT/ICD-10 coding review for molecular diagnostic testing to ensure accuracy, compliance, and payer alignment.
Establish a proactive coding audit program (frequency, sampling, root-cause tracking, remediation) to prevent avoidable denials and rework.
Maintain coding guidance and decision rules (including payer-specific nuances) and ensure adoption across impacted teams.
Oversee medical necessity reviews for prior authorizations and appeals, ensuring submissions are clinically supported and payer-policy compliant.
Define standards for clinical documentation requirements and evidence expectations by test type, indication, and payer.
Serve as escalation point for complex or high-risk cases (e.g., experimental/investigational classifications, policy exclusions, or documentation disputes).
Develop, maintain, and continuously improve standardized PA and appeal templates (including clinical narratives, letter structures, and documentation checklists).
Implement a template governance process (version control, payer policy refresh cadence, performance feedback loop) to ensure templates remain current and effective.
Partner with Market Access to interpret payer clinical policies and translate requirements into operational playbooks and submission standards.
Identify systemic policy gaps or recurring denial drivers and collaborate on mitigation plans (process, documentation, education, and payer engagement).
Establish and monitor KPIs such as PA approval rate, appeal overturn rate, clinical denial rate, and cycle times for authorization/appeals.
Produce recurring performance insights and root-cause themes; drive prioritized improvements that measurably reduce denials and improve approval outcomes.
Develop training and enablement materials to standardize best practices across teams and support onboarding.
Create and lead a cross-functional operating cadence (e.g., weekly denial/PA performance review, monthly policy change review).
Ensure consistent handoffs among Clinical Ops, RCM, and Market Access and embed accountability for corrective actions.
Ensure compliance with all company policies, procedures, and applicable regulatory requirements.
Maintain audit ready documentation and controls related to coding standards, template governance, and payer submission processes.
Perform other duties as assigned to support team and organizational objectives.