[Hiring] Manager Appeals & Rebuttals @American Recruiting & Consulting Group

Role Description

Responsible for providing leadership and direction of all Provider/Supplier Enrollment appeal (CAPs/reconsiderations) and rebuttal operations, utilizing analytical skills and regulatory knowledge to ensure timely and compliant adherence with all Provider Enrollment appeal and rebuttal contractual obligations, CMS program guidance and departmental procedures. This includes leading, managing, and providing direction for all appeals activities and rebuttal processes.

This position does not interpret statutes or regulations for the purpose of providing legal advice and does not act as an attorney for the organization. The Appeals Manager provides direct leadership and management for lower-level exempt and higher-level non-exempt individual contributors.

Essential Responsibilities

• Leadership, Operations, and Compliance (70%)
• Accountable for the oversight and effective management of all appeals and rebuttals.
• Lead, direct and manage the daily operations of the Durable Medical Equipment, Prosthetics, Orthotics and Suppliers (DMDPOS) appeals and rebuttals, including workflow management, quality review and staff development.
• Ensure appeal decisions are consistent with federal regulatory requirements, contractual obligations and CMS program guidance.
• Accountable for reviewing and operationalizing requirements outlined in Technical Direction Letters (TDLs), Change Requests (CRs), the Statement of Work (SOW), and the Medicare Program Integrity Manual (PIM).
• Review complex appeal cases to assess facts, apply existing policies and guide consistent outcomes.
• Identify trends, risks and process improvement opportunities and escalate matters appropriately.
• Serve as a key liaison and partner to internal and external legal counsel.
• Interact with the Centers for Medicare & Medicaid Services (CMS) and the Office of the General Counsel (OGC) as requested by CMS.
• Review and process appealable determinations and rebuttable determinations in accordance with applicable CMS program guidance.
• Coordinate with CMS and internal stakeholders to ensure appeals are supported with complete documentation, clear rationale, and consistent application of regulatory requirements.
• Appeal and Rebuttal Strategy and Risk Mitigation (15%)
• Lead the appeals (CAP/reconsideration) rebuttal strategy.
• Ensure appeals (CAP/reconsideration) and rebuttal narratives are supported by evidence, policy, and regulatory requirements.
• Establish and maintain processes and workflows that ensure appeals and rebuttals are handled timely and accurately.
• Identify trends in rebuttal and appeals that can be incorporated into training, policy updates, and process redesign.
• Cross-Functional Collaboration and Process Improvement (15%)
• Serve as subject matter expert and primary escalation contact for internal leaders, external partners, and regulatory bodies.
• Collaborate with Legal to ensure clear and accurate interpretation of regulatory authority and CMS guidance.
• Support cross-functional initiatives to reduce appeal and rebuttal volume through upstream improvements.
• Analyze data to identify patterns, compliance risks, and operational gaps.
• Present trends, risks, and recommendations to senior leadership.

Qualifications

• J.D. and/or LL.M degree from a law school accredited by the American Bar Association.
• Three (3) or more years of prior work experience in administrative law or post-Juris Doctor (J.D), and/or post-Master of Laws (LL.M) experience in legal writing and research.
• Five (5) or more years of prior supervisory/team lead experience in legal writing, legal research, and/or administrative law.
• Demonstrated ability to handle risk and uncertainty, cope with change, and make objective decisions based on limited information.
• Demonstrated ability to analyze workflow and benchmark data to identify process improvements and ensure compliance with Medicare regulations and performance requirements.
• Demonstrated oral, written and interpersonal communications skills.

Preferred Qualifications

• Supervisory or managerial experience in a Medicare production environment.

Benefits

• Salary, bonus potential, excellent benefits package.