Health Business Solutions LLC

Job Summary:

We are seeking a highly experienced and strategic Director of Clinical Appeals to lead our clinical appeals function across government and commercial payer markets. This role is responsible for setting strategy, overseeing operations, and ensuring regulatory compliance for the full lifecycle of clinical appeals—focusing on medical necessity denials and post-service claim rework.

The Director will lead both onshore and offshore clinical teams, including managers, nurses, and appeal writers. This role is vital to driving high-value overturn rates, increasing recoveries, ensuring clinical accuracy, and maintaining payer compliance. The ideal candidate is a results-driven leader with deep knowledge of payer policies, denial management, and clinical justification frameworks.

Key Responsibilities:

• Provide strategic leadership over all clinical appeals operations, including appeal development, submission, tracking, and resolution.
• Manage and mentor a multi-level team including Managers, Senior Nurses, Clinical Appeal Specialists, and offshore partners (e.g., Philippines-based staff).
• Develop and refine standard operating procedures (SOPs), quality assurance standards, and productivity benchmarks.
• Monitor regulatory, payer, and industry changes to ensure clinical appeal content and processes remain compliant and effective.
• Collaborate with executive leadership, compliance, legal, and audit teams to align appeals strategy with broader organizational goals.
• Oversee escalation processes for complex or high-dollar appeals and represent the company in payer discussions or hearings as needed.
• Analyze data trends to identify systemic denial issues, track success metrics (overturn rates, TAT, volume), and report outcomes to leadership and clients.
• Lead initiatives to optimize workflows, automate processes, and improve appeal quality and timeliness.
• Ensure training and ongoing development of clinical staff in line with evolving payer and regulatory requirements.
• Serve as a subject matter expert for appeal protocols, CMS guidance, and utilization review best practices.

Qualifications:

• Registered Nurse (RN) or equivalent clinical degree required; BSN or advanced clinical degree strongly preferred.
• 8+ years of experience in clinical appeals, utilization review, or care management, with 4+ years in a leadership or director-level role.
• Proven success managing large, distributed teams including remote and offshore resources.
• Deep knowledge of medical necessity standards, payer policies (Medicare, Medicaid, MA plans, commercial), and denial prevention strategies.
• Strong understanding of CMS guidelines, NCDs/LCDs, HIPAA, and payer audit processes.
• Excellent leadership, communication, and cross-functional collaboration skills.
• Proficiency in clinical appeal systems, denial management platforms, and analytics tools.

Preferred Certifications:

• CCM, CCDS, CPUR, ACM-RN, or similar
• Certification in healthcare compliance or clinical documentation improvement is a plus