Supervisor, Clinical Appeals/UM

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🇺🇸 United States – Remote

💵 $77k - $129k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Guidehouse

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2018

💰 Grant on 2023-02

Consulting • Digital Services • Public Sector

Guidehouse is a global consultancy offering advisory, digital, and managed services across commercial and public sectors. It is purpose-built to support industries such as national security, financial services, healthcare, energy, and infrastructure. Guidehouse collaborates with leaders to navigate complexity and drives transformational changes that impact the future. Their expertise spans data analytics, digital technologies, risk management, and more, with a strong emphasis on sustainability and innovation.

📋 Description

• 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.

🎯 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