Clinical Appeals Manager

Remote, CA 90802

Job ID: 2463 Industry: Nurse - Compliance/Appeals
The Clinical Appeals Manager will work in conjunction with the Director of Clinical Appeals to oversee the various functions of the Clinical Appeals Department for Managed Resources, Inc.  The Manager’ s responsibilities include review of appeal letters according to established company parameters, assists in quarterly audit reviews of nurses with the Director of Clinical Appeals, assists with quarterly reports for clients and attends meetings as needed, attend management meetings as needed via Skype, coordinates staff meetings with the Director, maintains a work queue of assignments, and other duties as needed if Director is unavailable.
Reports to:                   
Director of Clinical Appeals

Essential Job Functions:
Complete the following functions in accordance with Managed Resources policies:
  • The Clinical Appeals Manager will report directly to the Director of Clinical Appeals.
  • Reviews clinical appeal letters as designated by the Director of Clinical Appeals.
  • Assists Clinical Appeal Nurses as needed with questions, research, etc.
  • Assists Director with nurse audits as needed on a quarterly basis.
  • Assists with nurse assignments of client projects.
  • Ensure employee compliance with HIPAA regulations/training as required.
  • Assists the Director of Clinical Appeals with data gathering for month end and quarterly reports as needed.
  • Attends client meetings as needed and/or required.
  • Assists with reviewing appeal letters as necessary.
  • Provides input on content and direction of staff meetings.
  • Assists with yearly performance evaluations of Clinical Appeal Nurses.
  • Maintains personal work queue.
Ideal candidate will possess the following:
  • Registered Nurse with previous management experience preferred; BSN preferred.
  • Leadership skills to include:
    • Organizing a meeting, completing performance evaluations, ability to present Power Point demonstrations to clients.
  • Certified Case Manager and/or CCS a plus.
  • Possesses knowledge and experience with national clinical criteria applied in case management including InterQual and Milliman standards.
  • Working knowledge of billing codes, Revenue Codes, CPT’ s, etc.
  • Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
  • Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry based standards.
  • Experience and success in appealing managed care denials and underpayment decisions.
  • Ability to examine financial and clinical data trends and provide recommended action plan.
  • Integrity and commitment to excellence.

Managed Resources is an Equal Opportunity Employer (EOE) M/F/D/V/SO

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