Job Family:
Clinical Appeals Nurse

Travel Required:
None

Clearance Required:
None

What You Will Do:

The Clinical Appeals/UM RN Supervisor is responsible for overseeing a team of Registered Nurses conducting clinical denials management, appeal reviews, and payer dispute resolution activities. This role provides operational leadership, clinical guidance, quality oversight, and performance management to ensure timely and effective appeal submissions that maximize reimbursement and reduce revenue loss. The supervisor serves as a subject matter expert in utilization management, medical necessity criteria, payer regulations, and denial prevention strategies while fostering a high-performing and engaged team culture.

Key Responsibilities

Leadership & Staff Management
• Supervise, mentor, and develop a team of Clinical Appeals and Denials RNs.
• Conduct regular coaching sessions, performance reviews, and professional development planning.
• Monitor productivity, quality, and compliance metrics to ensure achievement of departmental goals.
• Facilitate team meetings, training sessions, and ongoing education initiatives.
• Manage staffing assignments, workload balancing, PTO coverage, and scheduling needs.

Clinical Appeals Oversight
• Oversee the review and management of medical necessity, authorization, and clinical validation denials.
• Ensure timely preparation and submission of first-level, second-level, and external appeals.
• Guide staff in developing evidence-based appeal arguments utilizing clinical documentation, regulatory requirements, and nationally recognized guidelines such as InterQual and MCG.
• Review complex and high-dollar denials and provide escalation support as needed.
• Ensure all appeals meet payer-specific requirements and submission deadlines.

Denials Management & Revenue Protection
• Analyze denial trends and identify root causes impacting reimbursement.
• Collaborate with Revenue Cycle, Case Management, Utilization Review, CDI, HIM, and Operational Leadership to implement denial prevention strategies.
• Monitor recoveries, overturn rates, appeal success metrics, and financial outcomes.
• Develop action plans to address payer performance concerns and recurring denial patterns.
• Participate in client and leadership meetings to present denials performance and recommendations.

Quality & Compliance
• Ensure adherence to organizational policies, regulatory requirements, and payer guidelines.
• Perform quality audits of appeal submissions and provide feedback to staff.
• Maintain expertise in CMS regulations, Medicare and Medicaid requirements, commercial payer policies, and industry best practices.
• Support audit readiness and compliance initiatives.

Operational Excellence
• Identify and implement process improvements that enhance efficiency, quality, and financial outcomes.
• Assist in developing standard operating procedures, workflows, and training materials.
• Utilize data analytics and reporting tools to monitor team effectiveness and operational performance.
• Support implementation of new clients, programs, and denial management initiatives.

What You Will Need:
• Active Registered Nurse (RN) license in good standing.
• Minimum of 5 years of clinical nursing experience.
• Minimum of 3 years of experience in clinical appeals, denials management, utilization management, case management, or revenue cycle operations.

What Would Be Nice To Have:
• Certified Case Manager (CCM), Accredited Case Manager (ACM), or related certification preferred.
• Experience supporting multiple hospital clients or health systems.
• Knowledge of hospital revenue cycle operations, payer contracting, and reimbursement methodologies.
• Experience with Epic and other clinical documentation systems.
• Previous leadership, supervisory, or team lead experience preferred.
• Strong knowledge of InterQual, MCG, Medicare, Medicaid, and commercial payer guidelines.
• Experience with electronic health records and utilization management systems.

#LI-DNI

The annual salary range for this position is $77,000.00-$129,000.00. Compensation decisions depend on a wide range of factors, including but not limited to skill sets, experience and training, security clearances, licensure and certifications, and other business and organizational needs.

What We Offer:

Guidehouse offers a comprehensive, total rewards package that includes competitive compensation and a flexible benefits package that reflects our commitment to creating a diverse and supportive workplace.

Benefits include:

• Medical, Rx, Dental & Vision Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community Outreach
• Emergency Back-Up Childcare Program