Job Description

MAJOR FUNCTION:

The Denial and Appeals Supervisor provides operational and clinical oversight for the utilization review, utilization management, denial prevention, denial management, and appeals functions within Care Coordination. This role supervises day-to-day workflows, monitors timeliness and quality standards, identifies and reports denial trends, and escalates complex payer issues as needed. Serves as a liaison between care coordination staff, payers, and internal physician advisors to ensure compliant, effective utilization management and appeal submissions. Collaborates with internal and external stakeholders to ensure compliance with state and national rules and regulations, payer contracts, and organizational policy; supports staff development through coaching, training, and performance feedback while maintaining clinical competency and current knowledge of regulatory and payor requirements.

QUALIFICATION:

Education & Experience:

• BSN required; MSN preferred.
• Registered Nurse licensure required.
• Prior supervisory/charge/lead experience (formal or informal) preferred.
• Minimum of 3 years clinical nurse experience.
• Minimum of 3 years of utilization review experience required.
• Minimum of 2 years recent case management experience required.
• Ongoing experience with payer portals and provider manuals as well as CMS regulations.

Certification/Licensure:

• Registered Nurse License Required.
• MCG Certification Preferred.
• Case Management Certification Preferred.

Knowledge & Skills:

• Demonstrates role-modeling behavior through professional and effective interpersonal communication with staff and external stakeholders.
• Must have knowledge and understanding of Centers for Medicare &Medicaid Services (CMS) guidelines and Conditions of Participation.
• Ability to work independently and set priorities efficiently under constraints of managed care guidelines.
• Ability to coordinate, compile, and analyze data. Maintain denial tracker and UM report (LOS, denial rate, turn around times, UM outliers).
• Excellent communication skills (oral and written) and interpersonal skills necessary to negotiate with families, patients, post-acute providers and third- party payors.
• Understanding of payer portals and provider manuals.

Physical Requirements:
N: Never O: Occasionally (80%)LiftingFStandingFSittingFLifting 20-50lbsOClimbingOKneelingOLifting>50lbsNCrouchingOReachingOCarryingFHearingCWalkingFPushingFTalkingCVisionC Environmental Conditions:NoiseFVaried TemperaturesOCleaning AgentsONoxious odorsOPatient ExposureFOperative EquipmentO

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