Job Summary:
We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role is responsible for overseeing day-to-day activities of clinical appeal specialists, managing appeal strategy execution, ensuring quality and compliance, and meeting client-specific performance goals.
The ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). This position is critical to ensuring timely and effective resolution of denied claims, supporting revenue recovery efforts, and maintaining payer and regulatory compliance.
Key Responsibilities:
- Manage the full-cycle clinical appeals process across multiple payer types, with a focus on government (e.g., Medicare, Medicaid) and commercial payers.
- Lead and support a team of nurses, clinical reviewers, and appeal specialists—including potential offshore (Philippines-based) staff.
- Monitor appeal workloads, productivity, and turnaround times to ensure all appeal deadlines and client service level agreements (SLAs) are met.
- Review and approve complex or high-value clinical appeal cases, ensuring clinical accuracy and compliance with payer guidelines.
- Maintain up-to-date knowledge of medical necessity criteria, payer policies, NCDs/LCDs, and applicable CMS regulations.
- Train new and existing team members on clinical guidelines, appeal writing standards, and regulatory requirements.
- Work cross-functionally with audit, legal, compliance, and operations teams to align on strategy and escalate trends or systemic payer issues.
- Identify and implement process improvements to increase efficiency, reduce denials, and improve overturn rates.
- Support the creation and refinement of appeal templates, clinical arguments, and documentation standards.
- Generate and deliver performance and quality reports to leadership, identifying risks and opportunities for improvement.
Qualifications:
- Registered Nurse (RN) or clinical degree required; Bachelor's degree in Nursing, Health Administration, or related field preferred.
- 5+ years of experience in clinical appeals, utilization review, or medical necessity denials.
- 2+ years in a leadership or supervisory role, preferably within a revenue cycle or payer appeals setting.
- In-depth understanding of payer denial processes, especially Medicare Advantage, Medicaid Managed Care, and commercial plans.
- Experience managing remote and/or offshore teams (Philippines experience preferred).
- Strong working knowledge of ICD-10, CPT, and HCPCS coding as they relate to clinical justifications.
- Excellent writing skills and the ability to clearly communicate complex clinical reasoning.
- Familiarity with appeal submission portals, EHRs, and workflow platforms.
- Knowledge of HIPAA, CMS, and NCQA standards.