Manager Appeals RN

The Manager, Clinical Appeals (RN) leads the end-to-end clinical appeals function for both member and provider appeals, ensuring decisions are clinically sound, timely, defensible, and fully compliant with applicable federal, state, and accreditation requirements. This role oversees RN reviewers and clinical staff, manages vendor/peer review workflows, and partners cross-functionally (Medical Directors, Compliance, Legal, UM, Customer Service) to optimize outcomes, reduce overturn rates, and deliver an excellent member and provider experience.

Key Responsibilities

Operational Leadership

·       Manage day-to-day operations of the clinical appeals team (RN reviewers, coordinators), including staffing, workload distribution, case assignment, and escalation management.

·       Ensure timely completion of appeals within regulatory and contractual turnaround times for all lines of business.

·       Oversee the clinical development of appeal rationales, including appropriate application of medical necessity criteria, plan policies, and evidence-based guidelines.

·       Coordinate independent review organization processes and file preparation for external review entity processing.

Regulatory & Compliance Oversight

·       Own and maintain workflows that comply with CMS (Medicare Parts C/D), applicable state regulations, ERISA, and NCQA standards as applicable.

·       Monitor regulatory changes; update policies, procedures, templates, and training materials; communicate changes and implementation timelines to staff.

·       Partner with Compliance teams on audits, corrective action plans, and risk mitigation; lead responses to internal/external audits and regulators.

·       Enforce HIPAA and privacy/security requirements across all appeal activities.

Quality & Performance Management

·       Track and regularly report on KPIs inclusive of: timeliness compliance, uphold and overturn rates, volumes, audit findings, mitigation strategies.

·       Oversee teams conducting quality reviews of clinical case files, rationales, and decision letters; implement coaching and targeted remediation.

·       Perform root cause analysis on overturns, grievances linked to appeals, and external review outcomes; drive process improvements with UM, Care Management, and Provider Relations.

·       Participate in the development of training curricula, competency assessments, and continuing education for RN reviewers and staff.

Cross-Functional Collaboration & Communication

·       Serve as the clinical appeals subject matter expert (SME) for internal stakeholders and external partners, including regulators and accreditation bodies when necessary.

·       Collaborate with Medical Directors on complex cases, medical necessity criteria interpretation, and clinical policy alignment.

·       Partner with Provider Relations to address provider concerns and reduce recurrent appeal drivers; support clinical education and feedback loops.

·       Draft and/or approve member and provider decision communications to ensure clarity, completeness, and compliance with regulatory content requirements.

Technology, Data, & Vendor Management

·       Optimize use of appeal platform and integration with organizational systems

·       Manage relationships and performance with IROs, peer review vendors, and delegated entities; oversee service-level agreements and quality metrics.

·       Leverage analytics to identify trends, forecast volumes, and inform staffing and process changes.