[Hiring] Clinical Appeals Supervisor @Managed Resources

Role Description

The Clinical Appeals Supervisor is responsible for direct oversight of the clinical appeals team ensuring high-quality appeal reviews are completed, and appeal letters are submitted timely. The Supervisor manages team schedules, monitors quality and productivity to ensure standards are met, and assists in the preparation of internal and external reports. The Supervisor provides day-to-day leadership, quality oversight, and staff development for the appeals team. This role requires strong medical necessity review experience, revenue cycle knowledge, organizational, communication, analytical skills, and sound clinical judgement to effectively guide staff.

Qualifications

• Current, active RN license (BSN preferred)
• 3-5 years of experience as a Supervisor of Clinical Appeals, Utilization Review, or similar position
• Credentialed in field of specialty (Case Management, Utilization Review, Legal Nurse) Preferred
• Minimum of five (5) years of experience in utilization review, clinical appeals
• Possess knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards
• Working knowledge of billing codes, Revenue Codes, CPT’s, NCD/LCDs, etc.
• Experience and knowledge of managed care contracts, account receivables and revenue cycle functions
• Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards
• Knowledge of managed care denials and underpayment decisions
• 2-3 years of experience performing education/training
• Demonstrated leadership skills and abilities including team building, conflict resolution, project management and effective decision making
• Experience researching and deciphering payer policies and regulations

Requirements

• Supervise the day-to-day operations of the clinical appeals team, including staff scheduling, workload assignments, and coverage planning.
• Provide direct supervision of staff, including participation in hiring, onboarding, coaching and performance management.
• Prepare and conduct annual employee performance evaluations in accordance with company guidelines and established HR processes.
• Review and approve employee timesheets in accordance with company timekeeping policies and procedures.
• Oversee the timely and accurate review, development, and submission of clinical appeals, ensuring established deadlines and payer requirements are consistently met.
• Review escalated or complex cases to determine appeal viability and provide guidance to staff on the appropriate clinical and regulatory approach.
• Escalate complex, high-risk, or potentially noncompliant cases to the Manager as appropriate.
• Monitor individual and team productivity, quality, and turnaround times against established benchmarks and performance expectations.
• Conduct regular audits and quality reviews of appeal cases, identify errors or delays, and provide feedback, coaching, and corrective action as needed.
• Monitor appeal inventory, outstanding cases, and submission deadlines to ensure timely completion and appropriate workload management.
• Analyze recurring denial trends and patterns, identify root causes and emerging risks, and provide management with actionable recommendations to improve appeal outcomes, reduce preventable denials, and support continuous process improvement.
• Monitor appeal outcomes, including upheld and overturned determinations, and analyze appeal success and overturn rates by payer, denial type, reviewer, service line, and other relevant categories.
• Evaluate payer responses and appeal outcomes to identify opportunities to improve appeal quality, accuracy, effectiveness, and overall team performance.
• Utilize denial and appeal data to identify coaching opportunities, training needs, workflow improvements, and denial prevention strategies; collaborate with the Manager to implement appropriate process improvements.
• Serve as a subject matter expert and resource for the Director, Manager, Team Leads, and Appeal Reviewers regarding clinical appeals, payer requirements, and related operational questions.
• Lead internal staff training and monthly team meetings as delegated by the Manager.
• Provide ongoing training, mentorship, and education to clinical appeals staff in collaboration with the Manager and Team Leads, supporting professional growth and competency development.
• Assist in preparing internal and external reports, performance summaries, training documents, and educational materials in collaboration with the Manager.
• Participate in client meetings, training sessions, and presentations as needed in partnership with the Manager.
• Maintain current knowledge of applicable regulatory changes, payer policies, coding guidelines, clinical review criteria, and screening standards, and ensure staff receive appropriate updates and education.
• Ensure team practices comply with organizational policies, applicable regulatory requirements, and HIPAA standards governing the access, use, and disclosure of protected health information.
• Perform other duties as assigned.

Benefits

• Medical, Dental, and Vision Insurance
• Phone and Internet Stipend
• Company-Paid Life Insurance
• 401(k) Retirement Plan with Company Match
• Paid Time Off
• Seven Company-Observed Holidays
• Two Floating Holidays for Personal Observance
• Professional Development Opportunities
• Employee Recognition Programs
• Remote Work Environment