Manager, Clinical Appeals

Health Business Solutions LLC; United States; Remote; USD 90,000 - 130,000; Full time

Job summary

Health Business Solutions LLC seeks an experienced Manager of Clinical Appeals to lead our national and offshore clinical appeals operations across government and commercial payers. You will supervise day-to-day activities of appeal specialists, guide strategy execution, and ensure quality and client-specific performance goals.

The ideal candidate brings a strong background in clinical review, medical necessity denials, and payer appeal processes, with proven leadership across teams including

Qualifications

• RN or clinical degree required; BSN preferred.
• 5+ years in clinical appeals, utilization review, or medical necessity denials.
• 2+ years in a leadership or supervisory role.
• Experience with Medicare Advantage, Medicaid Managed Care, and commercial payer denials.

Responsibilities

• Manage full-cycle clinical appeals across government and commercial payers.
• Lead a team including offshore staff.
• Monitor workloads, productivity, and SLAs.
• Review complex cases for accuracy and payer guidelines.
• Maintain knowledge of medical necessity criteria and CMS regulations.
• Train staff on guidelines and regulatory requirements.
• Collaborate with audit, legal, compliance, and operations teams.
• Identify process improvements to reduce denials and improve overturn rates.
• Support creation of appeal templates and documentation standards.
• Deliver performance and quality reports to leadership.

Skills

Clinical appeals

Leadership

Medical necessity

Regulatory compliance

Healthcare writing

Remote team management

Education

Bachelor's degree in Nursing, Health Administration, or related field

Tools

EHR systems

Appeal submission portals

Workflow platforms

Job description

Job Summary:

We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role is responsible for overseeing day-to-day activities of clinical appeal specialists, managing appeal strategy execution, ensuring quality and compliance, and meeting client-specific performance goals.

The ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). This position is critical to ensuring timely and effective resolution of denied claims, supporting revenue recovery efforts, and maintaining payer and regulatory compliance.

Key Responsibilities:

• Manage the full-cycle clinical appeals process across multiple payer types, with a focus on government (e.g., Medicare, Medicaid) and commercial payers.
• Lead and support a team of nurses, clinical reviewers, and appeal specialists—including potential offshore (Philippines-based) staff.
• Monitor appeal workloads, productivity, and turnaround times to ensure all appeal deadlines and client service level agreements (SLAs) are met.
• Review and approve complex or high-value clinical appeal cases, ensuring clinical accuracy and compliance with payer guidelines.
• Maintain up-to-date knowledge of medical necessity criteria, payer policies, NCDs/LCDs, and applicable CMS regulations.
• Train new and existing team members on clinical guidelines, appeal writing standards, and regulatory requirements.
• Work cross-functionally with audit, legal, compliance, and operations teams to align on strategy and elevate trends or systemic payer issues.
• Identify and implement process improvements to increase efficiency, reduce denials, and improve overturn rates.
• Support the creation and refinement of appeal templates, clinical arguments, and documentation standards.
• Generate and deliver performance and quality reports to leadership, identifying risks and opportunities for improvement.

Qualifications:

• Registered Nurse (RN) or clinical degree required; Bachelor's degree in Nursing, Health Administration, or related field preferred.
• 5+ years of experience in clinical appeals, utilization review, or medical necessity denials.
• 2+ years in a leadership or supervisory role, preferably within a revenue cycle or payer appeals setting.
• In-depth understanding of payer denial processes, especially Medicare Advantage, Medicaid Managed Care, and commercial plans.
• Experience managing remote and/or offshore teams (Philippines experience preferred).
• Strong working knowledge of ICD-10, CPT, and HCPCS coding as they relate to clinical justifications.
• Excellent writing skills and the ability to clearly communicate complex clinical reasoning.
• Familiarity with appeal submission portals, EHRs, and workflow platforms.
• Knowledge of HIPAA, CMS, and NCQA standards.