Supervisor, Clinical Appeals/UM

Jobtailor; Deutschland; Vor Ort; EUR 70.000 - 90.000; Vollzeit

Zusammenfassung

Jobtailor is seeking an experienced Nursing Leader to oversee a team of Clinical Appeals and Denials RNs in Germany. You will mentor staff, drive performance, and ensure compliant, timely denial management across payer types.

In this role you will develop coaching plans, monitor metrics, and collaborate with Revenue Cycle and Case Management to optimize outcomes while maintaining high-quality clinical documentation and regulatory adherence.

Qualifikationen

• Active 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.

Aufgaben

• 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 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 using clinical documentation and guidelines.
• 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.

Kenntnisse

Team Leadership

Coaching

Collaboration

Communication

Mentoring

Performance Metrics

Staff Development

Ausbildung

Registered Nurse License

Tools

CMS Regulations

InterQual & MCG Guidelines

Jobbeschreibung

Responsibilities

• 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.

Hard Skills

• Clinical Documentation
• Regulatory Requirements
• Payer-Specific Requirements
• Quality Audits
• Performance Metrics Monitoring
• Evidence-Based Appeal Arguments
• Action Plan Development
• Process Improvement
• Financial Outcome Analysis
• Staff Development

Soft Skills

• Team Leadership
• Coaching
• Collaboration
• Communication
• Mentoring

Certifications & Qualifications

• Registered Nurse (RN) License