Benefits
- Comprehensive Health Coverage – Medical, dental, and vision plans to keep you and your family healthy.
- Future Security: 401(k) with matching
- Student Loan Support – Up to $10,000 repayment assistance, because we invest in your future.
- Educational Tuition Assistance
- Competitive Pay & Full Benefits – A salary and package designed to reward your expertise and dedication.
Job Summary
The Supervisor, Clinical Appeals oversees the coordination of audit and medical necessity denial appeals for their assigned team. This role ensures timely and accurate appeal submissions, compliance with regulatory standards, and the achievement of service and production goals. The Supervisor provides day-to-day leadership, supports the development of standardized appeal processes, and works to identify trends and mitigate denial risks in collaboration with the Senior Director.
Essential Functions
- Supervises the team responsible for reviewing, preparing, and submitting medical necessity denial appeals in accordance with standardized processes and established timelines.
- Ensures timely communication with Recovery Audit Contractors (RACs) and other auditors, including managing requests for documentation and appeal submissions for all levels.
- Monitors team performance, ensuring compliance with regulatory requirements and appeal deadlines to maintain quality and efficiency.
- Conducts evidence-based research to support appeals for common denial reasons and provides team guidance to ensure accurate documentation.
- Identifies denial trends, compliance risks, and process improvement opportunities, reporting findings to the Senior Director of Appeals.
- Collaborates with physician advisors and senior leadership to address denial trends and support policy updates.
- Ensures accurate data collection and reporting through Compliance 360 or equivalent software, recommending system changes to improve tracking and reporting capabilities.
- Develops and delivers training to team members on appeals processes, compliance standards, and documentation requirements.
- Coaches and mentors team members to improve individual and team performance, providing customized feedback and conducting performance evaluations.
- Participates in Administrative Law Judge hearings and other legal processes as required.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
Qualifications
- H.S. Diploma or GED required
- Associate Degree in Nursing, Healthcare Administration, or a related field preferred
- 3-5 years of experience in healthcare appeals, denials management, or a related field required
- 1-2 years of leadership or supervisory experience preferred
Knowledge, Skills and Abilities
- Strong knowledge of healthcare appeals, denial management, and regulatory compliance.
- Proficiency in data management and tracking tools, including Compliance 360 or equivalent.
- Excellent leadership, coaching, and mentoring skills to support team development.
- Effective communication and collaboration skills to work with auditors, legal teams, and internal stakeholders.
- Strong analytical and problem-solving skills with the ability to identify trends and implement solutions.
- Proficiency in Google Suite, Microsoft Office Suite, and other relevant software applications.
Licenses and Certifications
- RN – Registered Nurse – State Licensure and/or Compact State Licensure preferred
The Payment Compliance and Contract Management (PCCM) team plays a critical role in ensuring that payments are made according to contractual agreements and regulatory requirements. The team oversees the full contract lifecycle, focusing on analyzing reimbursement discrepancies, improving revenue cycle processes, and ensuring compliance with contract terms to support financial accuracy and operational efficiency.
Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.
