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Supervisor, Clinical Appeals/UM
Location
United States
Posted
6 days ago
Salary
$77K - $129K / year
Seniority
Senior
Job Description
Supervisor, Clinical Appeals/UM
Guidehouse
• Supervise, mentor, and develop a team of Clinical Appeals and Denials RNs. • Conduct regular coaching sessions, performance reviews, and professional development planning. • Monitor productivity, quality, and compliance metrics to ensure achievement of departmental goals. • Facilitate team meetings, training sessions, and ongoing education initiatives. • Manage staffing assignments, workload balancing, PTO coverage, and scheduling needs. • Oversee the review and management of medical necessity, authorization, and clinical validation denials. • Ensure timely preparation and submission of first-level, second-level, and external appeals. • Guide staff in developing evidence-based appeal arguments utilizing clinical documentation, regulatory requirements, and nationally recognized guidelines such as InterQual and MCG. • Review complex and high-dollar denials and provide escalation support as needed. • Ensure all appeals meet payer-specific requirements and submission deadlines. • Analyze denial trends and identify root causes impacting reimbursement. • Collaborate with Revenue Cycle, Case Management, Utilization Review, CDI, HIM, and Operational Leadership to implement denial prevention strategies. • Monitor recoveries, overturn rates, appeal success metrics, and financial outcomes. • Develop action plans to address payer performance concerns and recurring denial patterns. • Participate in client and leadership meetings to present denials performance and recommendations. • Ensure adherence to organizational policies, regulatory requirements, and payer guidelines. • Perform quality audits of appeal submissions and provide feedback to staff. • Maintain expertise in CMS regulations, Medicare and Medicaid requirements, commercial payer policies, and industry best practices. • Support audit readiness and compliance initiatives. • Identify and implement process improvements that enhance efficiency, quality, and financial outcomes. • Assist in developing standard operating procedures, workflows, and training materials. • Utilize data analytics and reporting tools to monitor team effectiveness and operational performance. • Support implementation of new clients, programs, and denial management initiatives.
Job Requirements
- Active Registered Nurse (RN) license in good standing.
- Minimum of 5 years of clinical nursing experience.
- Minimum of 3 years of experience in clinical appeals, denials management, utilization management, case management, or revenue cycle operations.
Benefits
- Medical, Rx, Dental & Vision Insurance
- Personal and Family Sick Time & Company Paid Holidays
- Position may be eligible for a discretionary variable incentive bonus
- Parental Leave
- 401(k) Retirement Plan
- Basic Life & Supplemental Life
- Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
- Short-Term & Long-Term Disability
- Tuition Reimbursement, Personal Development & Learning Opportunities
- Skills Development & Certifications
- Employee Referral Program
- Corporate Sponsored Events & Community Outreach
- Emergency Back-Up Childcare Program
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