The posting
Why Orthofix?
Guided by our organizational values – Take Ownership | Innovate Boldly | Win Together – we collaborate closely with world-class surgeons and other partners to improve people’s quality of life. At Orthofix, we want team members who build relationships and share knowledge, challenge the status quo, and deliver results every day to help us achieve our vision to be the unrivaled partner in Med Tech.
Our global team of over 1,600 employees brings to market highly innovative, cost-effective, and user-friendly medical technologies that heal musculoskeletal pathologies for patients and the healthcare professionals who treat them. Looking to change people’s lives? Look no further.
JOB PURPOSE:
This role is responsible for the oversight and continuous improvement of the clinical appeals function, including establishing standards, workflows, quality controls, and reporting processes that support effective reimbursement operations. The position applies licensed clinical expertise and independent judgment to evaluate payer denials, develop appeal strategies, and ensure compliant and timely appeal submissions. Works cross-functionally to identify and address documentation, authorization, and reimbursement issues while driving process improvements that reduce revenue risk and optimize reimbursement outcomes.
DUTIES AND RESPONSIBILITIES (essential functions of position):
Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
- Lead the daily clinical appeals workflow, including intake, denial classification, appeal eligibility review, prioritization, assignment, submission, follow-up, escalation, and closure.
- Perform licensed clinical review of payer denials and supporting records to determine the clinical issue, documentation gap, applicable coverage requirement, and appropriate appeal pathway.
- Develop or oversee accurate, patient-specific appeal narratives that connect the clinical record, payer policy, medical necessity criteria, and supporting evidence without creating or altering treating-provider documentation.
- Compile complete appeal packages, including orders, clinical notes, certificates of medical necessity, payer correspondence, authorization records, policy excerpts, and other required documentation.
- Monitor payer-specific filing deadlines, appeal levels, submission requirements, aging, and status to reduce avoidable untimely or incomplete submissions.
- Establish standardized appeal templates, evidence checklists, case documentation standards, quality controls, and escalation rules.
- Create and maintain an appeals dashboard illustrating volume, aging, submission timeliness, overturn outcomes, denial category, payer trends, and dollars recovered or preserved.
- Identify recurring clinical, documentation, policy, authorization, coding, or process issues observed through appeals and communicate findings to the appropriate functional owner.
- Partner with the Senior Manager, Payer and Documentation Audits on documentation trends, audit support, and opportunities identified through appeals. Provide appeal data and clinical insight while preserving that function's ownership of audit strategy and enterprise revenue leakage initiatives.
- Collaborate with Sales Administration, Accounts Receivables, Payer Contracting, Legal, Compliance, Medical Affairs, Sales, and field teams to resolve case-specific barriers and improve appeal readiness.
- Support payer escalations, reconsiderations, peer-to-peer preparation, administrative hearings, and external review activities as permitted by applicable law, payer rules, and professional scope of practice.
- Provide practical education and feedback to internal stakeholders on payer clinical criteria, medical necessity documentation, common denial drivers, and appeal package requirements.
- Support California DME licensure, inspection readiness, policy maintenance, and other clinical oversight activities assigned to the licensed professional for the California office.
- Maintain current knowledge of applicable payer policies, Medicare and Medicaid requirements, California requirements, company policies, and professional licensure obligations.
- Maintain regular and reliable attendance at the designated Orthofix California office.
- Performs other duties as assigned
Education/Certifications:
- Active, unrestricted license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in the State of California, maintained in good standing throughout employment.
- Graduate of an accredited nursing program
- Current credentials and continuing education required to maintain California licensure
Experience, Skills, Knowledge and/or Abilities:
- Minimum of six years of experience in clinical appeals, denials, utilization management, clinical review, case management, reimbursement, or a closely related healthcare function.
- Experience reviewing medical records and applying payer coverage criteria, medical necessity requirements, and clinical documentation standards.
- Demonstrated ability to write or critically review clear, accurate, and persuasive clinical appeal narratives.
- Working knowledge of commercial, Medicare, and Medicaid payer processes, including appeal levels, filing requirements, authorizations, and medical necessity determinations.
- Ability to manage multiple cases, competing priorities, deadlines, and escalations with strong attention to detail and follow-through.
- Ability to distinguish clinical appeal issues from administrative, coding, billing, contracting, and legal issues and route matters to the appropriate owner.
- Ability to lead a defined operational function, establish workflows, monitor quality, coach others, and report results without requiring a Senior Manager or Director scope.
- Excellent written and oral communication skills, including the ability to translate clinical and payer requirements for non-clinical audiences.
- Sound judgment and commitment to patient privacy, confidentiality, compliance, and professional scope-of-practice boundaries.
- Proficiency with Microsoft Word, Excel, PowerPoint, Outlook, and case tracking or workflow systems.
- Must reside in California and work in office at the designated Orthofix California location. This position is not remote.
- Occasional business travel may be required.
- Regular attendance required.
PREFERRED QUALIFICATIONS
The education, knowledge, skills and/or abilities listed below are preferred qualifications in addition to the minimum qualifications stated above.
- Has established relationships with Clinical background a plus
- Experience in medical device environment
Additional Experience, Skills, Knowledge and/or Abilities:
- Experience with durable medical equipment, bone growth stimulation, bracing, medical devices, home medical equipment, or another payer-intensive clinical environment.
- Experience with clinical appeals involving medical necessity, prior authorization, experimental or investigational determinations, documentation deficiencies, or payer policy interpretation.
- Experience building or improving an appeals workflow, work queue, quality review process, dashboard, or team structure.
- Experience supporting payer audits, regulatory inspections, accreditation readiness, or corrective action activities.
- Familiarity with California Medi-Cal and California managed care organizations.
PHYSICAL REQUIREMENTS / ADVERSE WORKING CONDITIONS
The physical requirements listed in this section include but are not limited to the motor/physical abilities, skills, and/or demands required of the position in order to successfully undertake the essential duties and responsibilities of this position. In accordance with the Americans with Disabilities Act (ADA), reasonable accommodations may be made to allow qualified individuals with a disability to perform the essential functions and responsibilities of the position.
- Must be able to lift and transport products, literature to customer sites repetitively throughout each day.
- Lifting capacity up to approximately 20 to 30 pounds.
- Travel by auto and plane frequently.
- Ability to use PC or laptop computer and cell phone effectively.
- Eyesight and hearing must be correctable to standard level.
DISCLAIMER
The duties listed above are intended only as representation of the essential functions of this position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. The job description does not constitute an employment agreement between the employer and employee and is subject to change at the sole discretion of the employer. Nothing in this document alters an employee’s at-will employment status.
The anticipated salary for this position is $135,000.00 per year, (plus bonus based on performance) and benefits.
DISCLAIMER
The duties listed above are intended only as representation of the essential functions of this position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to the position. The job description does not constitute an employment agreement between the employer and employee and is subject to change at the sole discretion of the employer. Nothing in this document alters an employee’s at-will employment status.
We are committed to providing equal employment opportunities to all employees and applicants without regard to race (including traits historically associated with race, such as hair texture and protective hairstyles, including braids, locks, and twists), ethnicity, religion, religious creed (including religious dress and grooming practices), color, caste, sex (including childbirth, breast feeding, and related medical conditions), gender, gender identity or expression, sexual orientation, national origin, ancestry, citizenship status, uniform service member and veteran status, marital status, pregnancy, age (40 and over), protected medical condition (including cancer and genetic conditions), genetic information, disability (mental and physical), reproductive health decision-making, medical leave or other types of protected leave (requesting or approved for leave under the Family and Medical Leave Act or the California Family Rights Act), domestic violence victim status, political affiliation, or any other protected status in accordance with all applicable federal, state, and local laws.
This policy extends to all aspects of our employment practices including, but not limited to, recruiting, hiring, discipline, termination, promotions, transfers, compensation, benefits, training, leaves of absence, and other terms and conditions of employment.
