The Supervisor Appeals- RN is responsible for leading and overseeing the clinical appeals process across the full continuum of review, including first-level internal appeals, second-level reviews, expedited appeals, external reviews, Independent Review Organization (IRO) cases, and state-mandated review processes for fully insured and self funded lines of business.

This position provides day-to-day clinical and operational leadership for a team of clinical appeal RNs while ensuring compliance with federal and state regulations, accreditation standards, and internal policies. The RN Supervisor is accountable for the quality, timeliness, accuracy, and regulatory compliance of clinical appeal reviews and serves as a key liaison among Medical Directors, Utilization Management, and external business areas.

The ideal candidate possesses deep clinical and regulatory expertise in appeals and grievances operations, leadership experience, strong knowledge of external review programs, and the ability to drive performance, quality, and continuous improvement across the appeals continuum.

Primary Responsibilities

Clinical Operations Leadership

·         Supervise the daily operations of the Clinical Appeals team.

·         Provide leadership, guidance, coaching, and performance management for Clinical Appeal Nurses and supporting clinical staff.

·         Ensure timely and accurate completion of appeal reviews in accordance with regulatory requirements, accreditation standards, and organizational policies.

·         Monitor workloads, inventory levels, productivity, and service-level performance.

·         Support staffing plans, cross-training initiatives, and workforce development activities.

·         Serve as an escalation point for complex, high-risk, or sensitive clinical appeals.

Clinical Appeals Management

·         Oversee clinical appeals of denials from UM and delegated UM vendors across the entire appeal lifecycle of both internal and external appeal reviews.

·         Ensure appeal reviews include appropriate clinical analysis, evidence-based decision-making, and comprehensive documentation.

·         Collaborate with Medical Directors regarding cases requiring secondary review and escalation due to leadership and/or executive escalation.

·         Facilitate consistent application of utilization management guidelines and clinical review standards.

Regulatory Compliance & Audit Readiness

·         Maintain expert knowledge of Commercial Appeals and Grievances regulations and requirements.

·         Support regulatory audits, accreditation reviews, and compliance monitoring activities.

·         Participate in corrective action planning and implementation related to audit findings.

·         Ensure appeal files, documentation, and clinical rationale meet audit-readiness standards.

·         Monitor regulatory changes and communicate impacts to staff and leadership.

The role is expected to support audit readiness, compliance monitoring, corrective actions, and regulatory oversight activities consistent with Appeals & Grievances operational requirements.

Quality Assurance & Clinical Oversight

·         Conduct quality audits and case reviews to assess accuracy, consistency, and compliance.

·         Identify trends, root causes, and opportunities for process improvement.

·         Develop and implement corrective actions to address quality concerns and performance gaps.

·         Monitor overturn trends and identify opportunities to improve initial review accuracy.

The position is responsible for monitoring quality indicators, identifying trends, presenting data during regulatory performance workgroups, supporting corrective actions, and advancing operational excellence and compliance.

Team Leadership & Staff Development

·         Hire, train, mentor, and develop clinical appeals staff.

·         Conduct performance evaluations and coaching sessions.

·         Identify developmental opportunities to enhance regulatory, clinical, and operational knowledge.

·         Lead staff meetings, case discussions, calibration activities, and educational programs.

·         Foster a culture of accountability, quality, collaboration, and member advocacy.