Clinical Appeals Manager

orthofix; Carlsbad (CA); On-site; USD 110,000 - 140,000; Full time

Job summary

Orthofix in California is seeking an experienced Clinical Appeals Specialist to oversee and improve the payer denial appeals process. You will lead daily workflows, review records, and craft patient-specific appeal narratives that align with medical necessity and payer policies.

This role requires an active CA RN or LVN license, 6+ years in clinical appeals or related areas, and the ability to partner with cross-functional teams to reduce revenue risk and ensure timely submissions.

Qualifications

• Active, unrestricted CA license as RN or LVN.
• Graduate of an accredited nursing program.
• Current credentials and continuing education required to maintain CA licensure.
• Minimum of six years of clinical appeals or related healthcare experience.

Responsibilities

• Lead daily clinical appeals workflow including intake, denial classification, and submission follow-up.
• Perform licensed clinical review of payer denials to determine issues and pathways.
• Develop patient-specific appeal narratives connecting medical record, payer policy, and medical necessity.
• Assemble complete appeal packages with necessary documentation and authorization records.
• Monitor filing deadlines, levels, and aging to ensure timely submissions.
• Establish standardized templates, checklists, and quality controls for appeals.

Skills

Clinical appeals

Denials review

Payer policy interpretation

Medical Records review

Education

CA RN license

CA LVN license

Graduation from accredited nursing program

Job description

Why Orthofix?

Guided by our organizational values - Take Ownership | Innovate Boldly | Win Together - we collaborate closely with world-class surgeons and other partners to improve people's quality of life. At Orthofix, we want team members who build relationships and share knowledge, challenge the status quo, and deliver results every day to help us achieve our vision to be the unrivaled partner in Med Tech.

Our global team of over 1,600 employees brings to market highly innovative, cost-effective, and user-friendly medical technologies that heal musculoskeletal pathologies for patients and the healthcare professionals who treat them. Looking to change people's lives? Look no further.

JOB PURPOSE

This role is responsible for the oversight and continuous improvement of the clinical appeals function, including establishing standards, workflows, quality controls, and reporting processes that support effective reimbursement operations. The position applies licensed clinical expertise and independent judgment to evaluate payer denials, develop appeal strategies, and ensure compliant and timely appeal submissions. Works cross-functionally to identify and address documentation, authorization, and reimbursement issues while driving process improvements that reduce revenue risk and optimize reimbursement outcomes.

DUTIES AND RESPONSIBILITIES (essential functions of position)

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

• Lead the daily clinical appeals workflow, including intake, denial classification, appeal eligibility review, prioritization, assignment, submission, follow-up, escalation, and closure.
• Perform licensed clinical review of payer denials and supporting records to determine the clinical issue, documentation gap, applicable coverage requirement, and appropriate appeal pathway.
• Develop or oversee accurate, patient-specific appeal narratives that connect the clinical record, payer policy, medical necessity criteria, and supporting evidence without creating or altering treating-provider documentation.
• Compile complete appeal packages, including orders, clinical notes, certificates of medical necessity, payer correspondence, authorization records, policy excerpts, and other required documentation.
• Monitor payer-specific filing deadlines, appeal levels, submission requirements, aging, and status to reduce avoidable untimely or incomplete submissions.
• Establish standardized appeal templates, evidence checklists, case documentation standards, quality controls, and escalation rules.
• Create and maintain an appeals dashboard illustrating volume, aging, submission timeliness, overturn outcomes, denial category, payer trends, and dollars recovered or preserved.
• Identify recurring clinical, documentation, policy, authorization, coding, or process issues observed through appeals and communicate findings to the appropriate functional owner.
• Partner with the Senior Manager, Payer and Documentation Audits on documentation trends, audit support, and opportunities identified through appeals. Provide appeal data and clinical insight while preserving that function's ownership of audit strategy and enterprise revenue leakage initiatives.
• Collaborate with Sales Administration, Accounts Receivables, Payer Contracting, Legal, Compliance, Medical Affairs, Sales, and field teams to resolve case-specific barriers and improve appeal readiness.
• Support payer escalations, reconsiderations, peer-to-peer preparation, administrative hearings, and external review activities as permitted by applicable law, payer rules, and professional scope of practice.
• Provide practical education and feedback to internal stakeholders on payer clinical criteria, medical necessity documentation, common denial drivers, and appeal package requirements.
• Support California DME licensure, inspection readiness, policy maintenance, and other clinical oversight activities assigned to the licensed professional for the California office.
• Maintain current knowledge of applicable payer policies, Medicare and Medicaid requirements, California requirements, company policies, and professional licensure obligations.
• Maintain regular and reliable attendance at the designated Orthofix California office.
• Perform other duties as assigned.

Education/Certifications:

• Active, unrestricted license as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) in the State of California, maintained in good standing throughout employment.
• Graduate of an accredited nursing program.
• Current credentials and continuing education required to maintain California licensure.

Experience, Skills, Knowledge and/or Abilities:

Minimum of six years of experience in clinical appeals, denials, utilization management, clinical review, case management, reimbursement, or a closely related healthcare function.

Experience reviewing medical records and applying payer coverage criteria, medical necessity re