Manager, Clinical Appeals - Health Business Solutions LLC

Position Overview: The Manager of Clinical Appeals, reporting directly to the VP of Clinical Appeals, plays a critical role in overseeing a remote team of clinicians dedicated to managing and resolving appeals related to denied claims. This position ensures the team operates with precision, efficiency, and adherence to regulatory standards while optimizing outcomes.

Responsibilities:

Service Delivery:

• Team Leadership: Lead and supervise a remote team of clinical appeals specialists, ensuring alignment with performance goals and adherence to policies.
• Performance Management: Conduct regular performance evaluations, provide feedback, and implement development plans to enhance team effectiveness which include prioritizing and managing inventory.
• Clinical Oversight: Review complex clinical cases to devise effective appeal strategies, ensuring thorough documentation and clinical rationale.
• Trend Identification: Analyze appeal outcomes to identify trends causing denials, providing insights for upstream prevention strategies.
• Compliance Assurance: Ensure appeals comply with regulatory requirements and organizational standards through regular audits and quality assurance processes.
• Training and Development: Develop training programs on clinical documentation, appeal strategies, and regulatory updates to foster continuous learning within the team.

Leadership:

• Collaboration: Work closely with Clients, both internal and external, Utilization Management, Medical Directors, and Billing to expedite appeal resolutions and advocate for successful outcomes.
• Communication: Effectively communicate with internal and external stakeholders such as leadership, clients, physicians, and insurance companies to gather information and facilitate appeals.

Business Development:

• Reporting and Analysis: Prepare comprehensive reports and presentations summarizing appeal outcomes, trends, and performance metrics using tools like PowerPoint and Excel.
• Strategic Insights: Analyze data to identify root causes of claim denials and recommend strategies for process improvement and efficiency gains.

Culture:

• Ethical Standards: Uphold high ethical standards and confidentiality in all aspects of appeals management.
• Professional Development: Foster a culture of continuous learning and professional growth among team members.

Qualifications:

• Bachelor’s degree in nursing; master’s degree preferred.
• Active RN license required.
• Minimum of 5 years of experience in healthcare appeals management.
• 3-5 years of experience in a leadership role
• Current US passport
• Previous experience managing a remote team is essential.
• Familiarity with MCG or InterQual guidelines required.
• Proficiency in Microsoft Office Suite, particularly PowerPoint and Excel.
• Strong analytical skills with attention to detail.
• Excellent written and verbal communication abilities.
• Ability to prioritize tasks, multitask, and meet deadlines in a dynamic environment.

This job description provides a comprehensive overview of the Manager of Clinical Appeals role, emphasizing leadership in service delivery, collaboration, strategic analysis, and fostering a supportive team culture. The responsibilities outlined may evolve to meet organizational needs.

Location: Remote position with occasional travel within the US and overseas as required.

Reporting: Reports directly to the VP of Clinical Appeals.

This role is pivotal in driving the success of clinical appeals management, ensuring high-quality outcomes, and contributing to organizational growth and client satisfaction.