[Hiring] Clinical Claims Appeals Manager @Caris Life Sciences

Role Description

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.

Qualifications

• 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.

Requirements

• 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.

Benefits

• Ability to sit and/or stand for extended periods of time.
• Ability to perform repetitive motion associated with computer-based work.
• Ability to lift up to 15 pounds.
• The majority of work is performed in a desk or remote office environment.

Other

• This position may require periodic travel and occasional work during evenings, weekends, or holidays based on business needs.
• Responsibilities may be modified as organizational needs evolve.
• Individual must successfully complete pre-employment process, which includes criminal background check, drug screening, credit check (applicable for certain positions), and reference verification.
• This job description reflects management’s assignment of essential functions. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
• Caris Life Sciences is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.