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.
Improve reimbursement outcomes by strengthening clinical defensibility and coding integrity across PA and appeals.
Lead CPT/ICD-10 coding review for molecular diagnostic testing to ensure accuracy, compliance, and payer alignment.
Oversee medical necessity reviews for prior authorizations and appeals, ensuring submissions are clinically supported and payer-policy compliant.
Develop, maintain, and continuously improve standardized PA and appeal templates (including clinical narratives, letter structures, and documentation checklists).
Partner with Market Access to interpret payer clinical policies and translate requirements into operational playbooks and submission standards.
Establish and monitor KPIs such as PA approval rate, appeal overturn rate, clinical denial rate, and cycle times for authorization/appeals.

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.

Director, Clinical Operations – Coding

Key skills