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.
KEY RESPONSIBILITIES
- CPT / ICD-10 Coding Governance & Review
- 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.
- Clinical Medical Necessity Review (PA & Appeals)
- 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).
- Standardized PA & Appeal Template Development
- 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.
- Payer Clinical Policy Interpretation (with Market Access)
- 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).
- Performance Monitoring, Reporting & Continuous Improvement
- 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.
- Cross-Functional Operating Rhythm & Governance
- 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.
- Compliance & Risk Management
- 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.
- Other Duties
- Perform other duties as assigned to support team and organizational objectives.
QUALIFICATIONS
Required
- 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.
Preferred
- 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.
COMPETENCIES
- Payer Policy Translation: Converts payer medical policy requirements into actionable workflows, templates, and operating standards.
- Coding & Clinical Rigor: Applies strong coding and clinical judgment to reduce defects and improve payer defensibility.
- Operational Excellence: Builds scalable processes, governance, and repeatability across PA and appeals.
- Data-Driven Problem Solving: Uses KPI trends and root-cause analysis to prioritize and deliver measurable improvements.
- Cross Functional Leadership: Aligns stakeholders across RCM, Market Access, Clinical Ops, and Operations to drive outcomes.
These competencies can be aligned to Baylor Genetics values and leadership behaviors in performance expectations. Baylor Genetics core values include Patients and Customer Centricity, Learning, Excellence, Teamwork, and Integrity.
PHYSICAL DEMANDS AND WORK ENVIRONMENT
- Location: Remote
- Physical Demands: Frequently required to sit; regularly required to talk/hear; regular use of computer and standard office equipment.
- Work Environment: Office environment with regular interaction across clinical, operational, and commercial stakeholders.
- Travel Requirements: Occasional travel may be required, such as onsite meetings, vendor or payer sessions, or operational reviews.
EEO STATEMENT
Baylor Genetics is proud to be an equal opportunity employer committed to fostering an inclusive and diverse workplace. We welcome and encourage applicants from all backgrounds to apply. We do not discriminate on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, age, veteran status, disability, genetic information, pregnancy, childbirth, or any other status protected by applicable federal, state, or local law. If you need an accommodation during the application process, please contact our Human Resources team.
Note to Recruiters:
We value building direct relationships with our candidates and prefer to manage our hiring process internally. While we occasionally partner with select recruitment agencies for specialized roles, we do not accept unsolicited resumes from recruiters or agencies without a written agreement executed by the authorized signatory for Baylor Genetics ("Agreement"). Any resumes submitted to Baylor Genetics in the absence of an Agreement executed by Baylor Genetics' authorized signatory, will be considered the property of Baylor Genetics, and Baylor Genetics will not be obligated to pay any associated recruitment fees.