Director, Appeals
Quantum Health
full-time
Posted on:
Location Type: Remote
Location: Remote • Ohio • 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- 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 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
Requirements
- 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
Benefits
- Health, vision and dental coverage
- Life insurance
- Legal and identity protection
- Adoption assistance
- Employee Assistance Program (EAP)
- Teladoc services
- 401(k) plan with up to 4% employer match
- Paid Time Off (PTO)
- 7 paid holidays
- Parental leave
- Volunteer days
- Paid sabbaticals
- Tuition reimbursement up to $5,250 annually
- Certification/continuing education reimbursement
- Discounted higher education partnerships
- Paid trainings and leadership development
- Recognition as a Best Place to Work for 15+ years
- Modern workplace with casual dress code
- Full-service dining, free snacks and drinks
- Complimentary 24/7 fitness center with group classes
- Outdoor walking paths and game room
- Notary and dry-cleaning services
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical appealsutilization managementInterQualclinical data analysisreportingcomplianceworkflow developmentappeals process oversightperformance metrics monitoringdocumentation standards
Soft skills
leadershipcommunicationanalytical skillsorganizational skillscollaborationpresentation skillsproject managementaccountabilitytrustworthinessproblem-solving
Certifications
RNNPCEBS