Manager, Clinical Appeals

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.