Reimbursement Specialist - Appeals

Naveris•Waltham, MA

4d•Remote

About The Position

Naveris, a commercial stage, precision oncology diagnostics company, is seeking a Reimbursement Specialist - Appeals to join their team. This role focuses on post-submission reimbursement activities, specifically denials management and appeals to ensure accurate reimbursement across various insurance plans. The company's mission is to develop and deliver novel diagnostics that transform cancer detection and improve patient outcomes, with their flagship test being NavDx, a blood-based DNA test for HPV cancers.

Requirements

4+ years of experience in reimbursement, denials management, or revenue cycle management within a diagnostics company, laboratory, or commercial payer environment
Bachelor’s degree or equivalent experience
Strong understanding of medical benefit structures, including Federal, State, PPO, HMO, and indemnity plans
Working knowledge of CPT, ICD-10, and HCPCS coding, as well as LCD/NCD coverage and reimbursement guidelines
Proven ability to analyze denials, identify root causes, and resolve issues effectively
Strong attention to detail, judgment, and follow-through
Excellent verbal and written communication skills with a customer service mindset
Strong troubleshooting, organizational, and time-management skills
Ability to adapt to changing business needs
Self-starter who can work independently
Compliance with legal and regulatory requirements of HIPAA
Acceptance and adherence to all policies and standards at Naveris
Reporting any suspected violations or abuse
Complete HIPAA training when joining the company

Nice To Haves

Experience with Xifin, Quadax, or Telcor preferred

Responsibilities

Manage various denial types that may result in low-pay appeals, Level 1 appeals, and Level 2 appeals
Prepare higher-level appeals for leadership review and submission when required
Review and interpret Explanation of Benefits (EOBs) to determine contractual allowances and identify root causes of denials
Contact insurance companies and utilize payer portals to investigate denials, determine next steps, and perform appeals follow-up
Submit corrected claims and appeals in accordance with payer guidelines and timelines
Maintain accurate documentation of denials, appeals actions, and payer communications
Assist in developing and maintaining payer-specific appeals workflows and documentation
Communicate with patients and providers regarding appeals-related billing questions, EOBs, and financial responsibility in complex or escalated cases
Critically assess challenging situations and escalate to the Supervisor or leadership when appropriate
Maintain a strong understanding of the end-to-end reimbursement lifecycle and how appeals impact revenue outcomes
Utilize systems, tools, and vendor resources to support appeals activities efficiently
Prioritize multiple concurrent appeals and operate with a sense of urgency
Ensure compliance with all applicable billing regulations and company policies, including HIPAA
Comply with all Federal and State regulations related to billing and reimbursement