Develop and implement strategic plans for the clinical appeals program aligned with organizational goals
Lead a team of clinical reviewers, nurses, and support staff in managing appeals and grievances
Serve as a subject matter expert on clinical appeals, providing guidance and training to staff and leadership
Provide daily oversight and support to the teams
Ensure that all appeals and letters are completed within required timeframes
Develop and review monthly reports to ensure compliance and to identify any trends
Work with TPA partners to develop necessary workflows
Oversee the end-to-end appeals process, including intake, clinical review, documentation, and resolution
Ensure compliance with URAC and other regulatory bodies
Monitor performance metrics (e.g., turnaround times, overturn rates, quality scores) and implement process improvements
Review complex cases and provide clinical expertise in appeal determinations
Collaborate with Medical Directors and external physician advisors for secondary reviews
Maintain high standards of documentation and clinical rationale in all appeal responses
Liaise with payers, providers, and internal departments to resolve escalated cases
Partner with Legal, Compliance, and Quality teams to address regulatory inquiries and audits
Represent the appeals function in cross-functional committees and initiatives
Provide reporting for Client Executives for their groups; maintain monthly appeals/non-certification reporting
All other duties as assigned.

Professional designation as RN, NP or CEBS preferred
Minimum 7 years of healthcare experience, with at least 3 years in utilization management or appeals
Strong knowledge of InterQual and payer policies, (e.g. ERISA and the ACA)
Proven leadership experience in a healthcare setting including leading people and teams
Excellent written and verbal communication, analytical, and organizational skills
Experience with electronic medical record systems and utilization management platforms preferred
Strong analytical skills with the ability to interpret complex clinical data and translate it into presentation and actionable insights
Exceptional presentation and communication skills, with experience presenting to clients
Ability to work collaboratively with cross-functional teams and external consultants
Strong organizational skills and the ability to manage multiple projects simultaneously
Proficient in using healthcare data management software and audit tools
A high degree of personal accountability and trustworthiness

Health, vision and dental featuring best-in-class healthcare navigation services
Life insurance
Legal and identity protection
Adoption assistance
EAP
Teladoc services
401(k) plan with up to 4% employer match and full vesting on day one
Paid Time Off (PTO)
7 paid holidays
Parental leave
Volunteer days
Paid sabbaticals
Tuition reimbursement up to $5,250 annually
Certification/continuing education reimbursement
Discounted higher education partnerships
Paid trainings and leadership development
Recognition as a Best Place to Work for 15+ years
Casual dress code
Open floor plans
Full-service dining
Free snacks and drinks
Complimentary 24/7 fitness center with group classes
Outdoor walking paths
Game room
Notary and dry-cleaning services

Director, Appeals

Key skills