Description:
Job Title: Appeals Nurse Manager
Company: Physician Care Coordination Consultants (PC3)
Location: Remote
Job Type: Full-time
Job Classification:
This is an exempt position under the Fair Labor Standards Act (FLSA) and is not eligible for overtime pay.
Our Mission:
Our mission is to drive financial wellness in healthcare organizations so more patients can receive the care they need.
Our Vision:
Our vision is a future where we help healthcare organizations thrive in a complex ecosystem by clearing a path to financial health.
Our Culture:
We are committed to creating a workplace where every member feels valued, empowered, and inspired to contribute their best. Together we will foster a culture that promotes work-life balance and celebrates community engagement, personal achievements, milestones, and special occasions.
Values:
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Integrity – We do what’s right, no matter what.
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Innovation – We use a harmonious blend of data, tech, and a human-centric approach.
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Compassion – We understand the stress of healthcare organizations and their patients.
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Determination – Our mission is our guiding force.
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Partnership – We build enduring relationships through listening, communication and accountability.
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Dignity– We have significant pride in each other and our work.
Job Summary: Appeals Nurse Manager is responsible for providing leadership and oversight of the clinical appeals function, ensuring that denied medical claims and services are thoroughly evaluated, clinically supported, and appealed in accordance with payer requirements, applicable regulatory standards, and evidence-based medical necessity criteria.
The Appeals Nurse Manager leads a team of Appeals Nurses and is responsible for establishing workflows, monitoring productivity and quality, reviewing complex and high-dollar denials, and ensuring timely submission of well-supported appeals. This position serves as a clinical resource to the appeals team and collaborates closely with physicians, leadership, utilization management, case management, coding, clinical documentation integrity, billing, and other revenue cycle departments.
The Appeals Nurse Manager is also responsible for identifying denial trends, analyzing appeal outcomes, developing strategies to improve overturn rates, and identifying opportunities to prevent future denials. The position requires a strong understanding of clinical documentation, medical necessity, payer policies, CMS requirements, and the hospital revenue cycle.
This position reports directly to the Associate Director of Revenue Cycle.
Supervisory Responsibilities: This position will have supervisory responsibilities for all Revenue Cycle Appeals Nurses.
Duties/Responsibilities:
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Provide day-to-day leadership, direction, and oversight to the Appeals Nursing team.
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Establish and maintain standardized workflows, processes, and performance expectations for clinical appeals.
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Assign and distribute appeal workload based on staff expertise, priority, complexity, and financial impact.
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Monitor staff productivity, timeliness, quality, and appeal outcomes.
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Conduct regular quality reviews and audits of appeal cases and documentation.
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Coach, mentor, and develop Appeals Nurses to strengthen clinical review and appeal-writing skills.
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Identify training opportunities and develop educational resources related to clinical appeals, medical necessity, payer requirements, and denial prevention.
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Participate in hiring, onboarding, performance management, and professional development of appeals staff.
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Ensure team compliance with organizational policies, client expectations, payer requirements, and regulatory standards.
Clinical Appeals & Denial Management
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Oversee the review of denied inpatient and outpatient claims and services to determine the clinical basis for appeal.
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Review medical records, clinical documentation, authorization information, payer policies, and applicable clinical guidelines to determine whether a denial is appropriately supported.
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Provide clinical oversight for complex, high-dollar, and high-priority denials.
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Ensure appeals clearly establish the patient's clinical condition, severity of illness, services provided, medical necessity, and rationale for the level and intensity of care.
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Review and approve complex appeal letters, reconsideration requests, and supporting documentation prior to submission when appropriate.
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Assist Appeals Nurses with difficult or escalated cases requiring advanced clinical judgment.
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Coordinate physician involvement in peer-to-peer reviews and physician advisor escalations when appropriate.
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Ensure appeals are submitted accurately and within payer and regulatory deadlines.
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Maintain awareness of applicable CMS regulations, Medicare requirements, Medicaid requirements, commercial payer policies, and other applicable reimbursement guidelines.
Revenue Cycle & Denial Prevention
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Analyze appeal outcomes, denial trends, and root causes to identify opportunities for improved revenue recovery.
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Monitor overturn rates and other key performance indicators to evaluate the effectiveness of the appeals process.
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Identify recurring clinical, documentation, authorization, coding, or process-related issues contributing to denials.
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Develop and implement denial prevention strategies in collaboration with appropriate operational and clinical departments.
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Provide feedback to clinical and revenue cycle leadership regarding trends affecting reimbursement.
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Identify opportunities to improve documentation and clinical processes that may prevent future denials.
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Assist in developing client-specific denial management strategies and action plans.
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Evaluate the financial impact of denials and prioritize work based on potential revenue recovery, clinical complexity, payer requirements, and appeal opportunity.
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Collaborate with coding, CDI, utilization management, case management, patient access, authorization, billing, and other revenue cycle functions to address the root cause of denials.
Client & Cross-Functional Collaboration
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Serve as a clinical appeals subject matter expert for clients and internal leadership.
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Participate in client meetings, denial review sessions, and performance discussions as needed.
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Communicate appeal performance, trends, barriers, and opportunities to leadership and clients.
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Work collaboratively with physicians, nurses, case managers, utilization review staff, coders, CDI professionals, and revenue cycle leaders.
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Provide clinical education and feedback to client organizations regarding denial trends and opportunities for improvement.
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Escalate significant clinical, operational, compliance, or payer-related concerns to appropriate leadership.
Quality, Compliance & Reporting
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Establish and monitor quality standards for clinical appeal reviews and written appeals.
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Conduct routine audits to ensure appeals are clinically accurate, appropriately supported, and compliant with payer requirements.
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Monitor appeal aging and ensure timely follow-up on outstanding cases.
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Maintain accurate records of appeal activity, outcomes, and supporting documentation.
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Develop and maintain performance reports related to appeal volume, turnaround time, overturn rate, financial recovery, and other key metrics.
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Ensure appropriate documentation is maintained for compliance, auditing, and client reporting.
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Participate in internal and external audits related to appeals and denial management.
Requirements:
Knowledge/Skills/Abilities:
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Strong knowledge of clinical documentation, medical necessity criteria, utilization management principles, and healthcare reimbursement.
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Strong understanding of Medicare, Medicaid, commercial payer policies, and applicable regulatory requirements.
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Knowledge of clinical criteria and utilization management tools, including InterQual and/or MCG (formerly Milliman), as applicable.
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Demonstrated ability to interpret complex medical records and apply advanced clinical judgment.
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Strong understanding of inpatient and outpatient hospital services and the relationship between clinical documentation and reimbursement.
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Excellent analytical, critical-thinking, problem-solving, and decision-making skills.
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Demonstrated ability to analyze denial and appeal data and identify trends and root causes.
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Excellent written and verbal communication skills, including the ability to develop persuasive, clinically supported appeal arguments.
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Strong leadership, coaching, mentoring, and team-building skills.
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Ability to prioritize workload based on financial impact, clinical complexity, deadlines, and likelihood of successful appeal.
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Strong organizational skills and attention to detail.
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Ability to manage multiple priorities and meet strict payer and organizational deadlines.
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Proficiency with electronic health records (EHR), claims systems, payer portals, Microsoft Office, and other revenue cycle technology.
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Ability to work independently while effectively collaborating with multidisciplinary teams.
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Ability to communicate complex clinical and reimbursement issues to both clinical and non-clinical audiences.
Education and Experience:
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Bachelor's degree in Nursing (BSN) from an accredited nursing program with a minimum of 5 years of clinical nursing experience, with 2 of those years in utilization review, case management, clinical appeals, denials management, or a related revenue cycle function.
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In lieu of bachelor’s degree, associate degree in Nursing from an accredited nursing program with a minimum of 8 years clinical nursing experience, with 4 of those years in utilization review, case management, clinical appeals, denials management, or a related revenue cycle function.
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1 year of prior leadership, supervisory, or management experience required.
Licensure:
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Active and unrestricted Registered Nurse (RN) license in applicable state(s). Compact licensure accepted where applicable.
Certifications:
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Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), or other relevant certification preferred.
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Certification or formal training in utilization management/medical necessity review is a plus.
Physical Requirements:
Prolonged periods of sitting at a desk and working on a computer.
Must be able to lift up to 15 pounds at times.
