Senior Manager, Clinical Appeals & Denials

Health Business Solutions LLC; Florida; On-site; USD 130,000 - 165,000; Full time

Job summary

Health Business Solutions LLC seeks an experienced Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role oversees day-to-day activities of clinical appeal specialists, manages appeal strategy execution, and ensures quality and compliance to meet client-specific performance goals.

The ideal candidate brings strong clinical review, medical necessity denials, payer appeal processes, and team leadership—across U.S.

Qualifications

• Bachelor's degree in Nursing, Health Administration, or related field required
• 5+ years of experience in clinical appeals, utilization review, or medical necessity denials
• 2+ years in a leadership or supervisory role, preferably in revenue cycle or payer appeals
• Strong understanding of payer denial processes (Medicare Advantage, Medicaid, commercial)
• Experience managing remote and/or offshore teams (Philippines preferred)
• Proficient in ICD-10, CPT, HCPCS coding for clinical justifications
• Excellent writing and communication of complex clinical reasoning
• Familiar with appeal submission portals, EHRs, and CMS/NCQA standards

Responsibilities

• Manage full-cycle clinical appeals across multiple payer types, focusing on government and commercial payers
• Lead and support a team of nurses, clinical reviewers, and appeal specialists, including offshore staff
• Monitor workloads, productivity, and SLAs to meet deadlines
• Review and approve complex high-value clinical appeal cases for accuracy and compliance
• Maintain up-to-date knowledge of medical necessity criteria and payer policies
• Train team members on clinical guidelines, appeal writing, and regulatory requirements
• Collaborate with audit, legal, compliance, and operations to align strategy
• Identify and implement process improvements for efficiency and overturn rates
• Develop and refine appeal templates and documentation standards
• Deliver performance and quality reports to leadership with risks and opportunities

Skills

RN license

Clinical appeals

Leadership

Remote team leadership

Payer denial processes

Offshore team management

ICD-10/CPT/HCPCS knowledge

Clinical documentation

EHR workflow

HIPAA/CMS/NCQA knowledge

Education

Bachelor's degree in Nursing or Health Administration

Job description

Health Business Solutions LLC seeks an experienced Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers. This role oversees day-to-day activities of clinical appeal specialists, manages appeal strategy execution, and ensures quality and compliance to meet client-specific performance goals.

The ideal candidate brings strong clinical review, medical necessity denials, payer appeal processes, and team leadership—across U.S.