Clinical Utilization & Appeals Leader

Catholic Health Services; Melville (NY); On-site; USD 110,000 - 150,000; Full time

Job summary

Catholic Health is seeking an experienced Utilization and Appeals Manager to lead clinical reviews and regulatory submissions across payors. The role serves as a liaison between clinical teams and managed care, identifying denial reasons and improvement opportunities.

Strong nursing background and prior appeals experience are essential. You will collaborate with the Catholic Health Physician Advisor, manage certification and appeal statuses, and ensure timely, compliant documentation in a busy

Qualifications

• Graduate of an accredited nursing program; NYS RN license required.
• Minimum 5+ years of clinical medical-surgical or applicable experience.
• Experienced in appeals writing and care management in an acute hospital or managed care setting.
• Proficient with EPIC, Midas, Star and other hospital software.

Responsibilities

• Manage and submit clinical reviews and appeals within deadlines.
• Identify denial reasons and work with payors/regulators for improvement.
• Collaborate with the Catholic Health Physician Advisor on cases.
• Communicate patient status and level of care changes to MCC as needed.
• Attend meetings and participate on committees.

Skills

RN license NY

Care management

Appeals writing

Clinical review

Evidence-based guidelines

Education

RN degree NYS

BSN preferred

Tools

EPIC

Midas

STAR

Job description

Catholic Health is seeking an experienced Utilization and Appeals Manager to lead clinical reviews and regulatory submissions across payors. The role serves as a liaison between clinical teams and managed care, identifying denial reasons and improvement opportunities.

Strong nursing background and prior appeals experience are essential. You will collaborate with the Catholic Health Physician Advisor, manage certification and appeal statuses, and ensure timely, compliant documentation in a busy