DescriptionLocation: This position is located at our Dublin, OH campus with remote/hybrid flexibility
About the role
The Director of Appeals leads and manages the clinical appeals function within the Utilization Management department. This role ensures timely, accurate, and clinically sound responses to appeals and grievances, while maintaining compliance with regulatory standards and payer requirements. The Director collaborates with internal and external stakeholders to optimize appeal outcomes and drive continuous improvement in clinical review processes.
What you'll do
- 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 our TPA partners to develop any 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.
What you'll bring (Qualifications)
- Healthcare experience - 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, a commitment to working within Quantum Health's policies, values and ethics, and to protecting the sensitive data entrusted to us.
- Strong administrative/technical skills; Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
- A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health's policies, values and ethics, and to protecting the sensitive data entrusted to us.
#LI-HW1 #LI-Remote
What's in it for you- Compensation: Competitive base and incentive compensation
- Coverage: Health, vision and dental featuring our best-in-class healthcare navigation services, along with life insurance, legal and identity protection, adoption assistance, EAP, Teladoc services and more.
- Retirement: 401(k) plan with up to 4% employer match and full vesting on day one.
- Balance: Paid Time Off (PTO), 7 paid holidays, parental leave, volunteer days, paid sabbaticals, and more.
- Development: Tuition reimbursement up to $5,250 annually, certification/continuing education reimbursement, discounted higher education partnerships, paid trainings and leadership development.
- Culture: Recognition as a Best Place to Work for 15+ years, dedication to diversity, philanthropy and sustainability, and people-first values that drive every decision.
- Environment: A modern workplace with a 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 and more!
What you should know- Internal Associates: Already a Healthcare Warrior? Apply internally through Jobvite.
- Process: Application > Phone Screen > Online Assessment(s) > Interview(s) > Offer > Background Check.
- Compensation Ranges: Compensation details published by job boards are estimates and not verified by Quantum Health. Details surrounding compensation will be disclosed throughout the interview process. Compensation offered is based on the candidate's unique combination of experience and qualifications related to the position.
- Sponsorship: Applicants must be legally authorized to work in the United States on a permanent and ongoing future basis without requiring sponsorship.
- Agencies: Quantum Health does not accept unsolicited resumes or outreach from third-parties. Absent a signed MSA and request/approval from Talent Acquisition to submit candidates for a specific requisition, we will not approve payment to any third party.
