Appeals Supervisor Job Description

Appeals Supervisor Job Description

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Appeals supervisor provides clinical leadership and supervision in assessment, treatment planning and clinical interventions provided by licensed therapists in the hospital outpatient setting.

Appeals Supervisor Duties & Responsibilities

To write an effective appeals supervisor job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals supervisor job description templates that you can modify and use.

Sample responsibilities for this position include:

Knowledgeable of Medicare and Medicaid Regulations, and Managed Care policies in the hospital setting, and or geographical region, Medicare Condition of Participation ( CoP ) for utilization review, and discharge planning for hospitals
Knowledgeable of hospital billing, reimbursement and the billing cycle, including but not limited to Hospital Medicare Part B -12x billing, Medicare Code 44-inpatient to outpatient, billable outpatient in a bed services
Excellent knowledge of the denial/appeal process, Governmental and Third party case review audits
Minimum 3 years’ experience in an acute care hospital
Three (3) years’ experience as a hospital Case Manager or Utilization Review Nurse
Two (2) years’ utilization review, resource management, and denial management experience
Case Management Certification / Accreditation
BS in Nursing or related field preferred
Supervisor or Manager experience preferred
Knowledgeable of hospital case management services which include hands-on experience with the application of InterQual or Milliman Care Guidelines Monitoring Tools, Principles of Managed Care

Appeals Supervisor Qualifications

Qualifications for a job description may include education, certification, and experience.

Education for Appeals Supervisor

Typically a job would require a certain level of education.

Employers hiring for the appeals supervisor job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Nursing, Healthcare, Law, Business, Management, Health, Health Care, Technical, Science

Skills for Appeals Supervisor

Desired skills for appeals supervisor include:

Word and Excel
Applicable law and resources regarding confidentiality of privileged patient information and appeals administration
Billable outpatient in a bed services
Denial/appeal process
Discharge planning for hospitals
Geographical region
Governmental and Third party case review audits
Hospital billing
Managed Care policies in the hospital setting
Medicare Code 44-inpatient to outpatient

Desired experience for appeals supervisor includes:

Skilled in denial prevention and appeals management, Recovery Audits, Third Party Audits, Experience with internal case review audits, identifying denial trends and areas for process improvement and education
Identifies and solves complex or nonstandard problems on own
Reviewing all Quality defects findings on regular basis, perform random or focused quality checks as needed to improve individual and departmental overall quality metrics
Regularly audits work of G&amp
Case Management Certification / Accreditation preferred
Provide support to the processes of appealing hospital claims which were denied based on medical need

Appeals Supervisor Examples

1

Appeals Supervisor Job Description

Job Description Example
Our innovative and growing company is hiring for an appeals supervisor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals supervisor
  • Provides expertise, leadership and technical support to the Medicare Appeals and Grievances and teams
  • Educates team as new procedures are developed, reviews procedures with staff as needed and monitors staff to ensure that procedures are implemented and adopted as standard practice
  • Leads efforts for associate engagement, development and other essential administrative tasks
  • Analyzes daily workflow of Appeals Specialists and Team leaders to ensure cases are handled thoroughly and kept within compliance timeframes
  • Reviews management reports and controls unit inventory levels by monitoring volumes, productivity and staffing on a daily basis
  • Identifies root causes for out of compliance cases and establishes corrective action plans
  • Identifies barriers to success, develops recommendations and participates in implementation
  • Clarifies benefit interpretation and collaborates with Member Services, Benefits, Legal, Compliance, Marketing, Enrollment, CMC, Medical policy, AIM, Magellan and other areas to report and resolve issues related to Appeals and Grievances
  • Collaborates with staff to ensure that established productivity, timeliness and accuracy standards are attained in accordance with Corporate, NCQA, State and Federal standards
  • Participates with Member Appeals management team in the planning and modification of the appeals process
Qualifications for appeals supervisor
  • Set in a high-volume, fast-paced office environment
  • Responsible for the support of weekend staff including holidays and other days that the office is closed
  • Participation in Corporate, External and CMS audits of Appeals and Grievance Cases
  • Bachelor’s Degree preferred and 3 years of experience in a customer setting or equivalent
  • In lieu of degree, 5 years of experience in Member Services, Provider Services, Claims, Complaint handling or equivalent
  • Prior experience in Member Appeals preferred
2

Appeals Supervisor Job Description

Job Description Example
Our company is searching for experienced candidates for the position of appeals supervisor. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for appeals supervisor
  • Develop policy and procedures performance standards by which to monitor the department’s progress
  • Recruit, interview, and hire staff based on candidate’s qualifications
  • Interact effectively with BCBST personnel within medical management, operations, Provider Networks and Contracting, and executive management external members and providers
  • Review and monitor all high dollar appeals for accuracy and appropriateness
  • Ensure accuracy and timeliness of all escalated appeals
  • Complete action required for escalated account workflow pools
  • Monitor high balance account pools to ensure acceptable inventory levels
  • Provide department-based training and support
  • Conduct department quality reviews
  • Maintain training and reference material on SharePoint site
Qualifications for appeals supervisor
  • Demonstrated excellence in prior leadership role/s
  • Demonstrated organizational, interpersonal, written and verbal communication skills required
  • Ability to prioritize work and analyze workflows
  • Demonstrate strong skills in use of Highmark and PBM systems
  • Must have good organization skills and be able to prioritize
  • Must excel at motivation, coaching and counseling others
3

Appeals Supervisor Job Description

Job Description Example
Our company is growing rapidly and is looking for an appeals supervisor. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for appeals supervisor
  • Participate on facility denial calls/lead calls as needed
  • Support department report production
  • Provide first level review and approval of adjustment transactions
  • Review facility/payer based issues identified and maintain department issues log
  • Lead special inventory projects as assigned
  • Approve and enter time exceptions/updates in Kronos
  • Monitor team attendance
  • Provide team members with routine feedback on individual quality and productivity performance
  • Provide coverage for coordinators and appeal specialists during vacation/leaves
  • Manages staff and operations
Qualifications for appeals supervisor
  • Minimum 5 years of demonstrated medical management, or operational experience or clinical experience (if RN) required
  • Minimum 2 years of managed care experience, or experience with regulatory or accrediting body requirements (i.e., NCQA, URAC, EQRO, CMS, TennCare) required
  • Minimum 2 years supervisor experience or previous experience leading a team or directing the work of others required
  • Personal computer operation with skills in various software applications, including word processing, spreadsheets, electronic mail and presentation programs
  • Extensive product, distribution and Claims industry knowledge
  • Microsoft Office tools (Outlook, Excel, Word)
4

Appeals Supervisor Job Description

Job Description Example
Our growing company is looking to fill the role of appeals supervisor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals supervisor
  • Manage the Appeals Team Inbox, including coordination of call assignments to appropriate appeals
  • Coordinator and monitor volume of all calls in the queue
  • Serve as back-up to the Doctor Review Inbox, including coordination of call assignments to appropriate Physician Advisor Reviewers and monitor volume of all calls in the queue
  • Support Manager of Appeals for all appeal documents related to new implementations, including testing to ensure that all documentation related to new implementations are accurate and meeting quality standards
  • Provide direct guidance to company and contractor employees by supervising, motivating, and monitoring staff to ensure compliance with appeals procedures and standards
  • Oversee workflow management of approved processes
  • Accomplish staff results by communicating job expectations and planning, monitoring, and appraising job results, coaching and counseling employees
  • Utilize control systems and procedures to maximize productivity
  • Complete special projects by organizing and coordinating information and requirements planning, arranging and meeting schedules
  • Perform reopening’s and all essential post-adjudication responsibilities
Qualifications for appeals supervisor
  • Hospital patient accounting and billing systems
  • LPN or RN with current license to practice required
  • Several years’ of clinical nursing experience required
  • Bachelor’s degree in healthcare, business, or related field preferred
  • Couple years’ of experience supervising non-exempt, hourly staff strongly preferred
  • May require department-specific license, certifications and/or designations
5

Appeals Supervisor Job Description

Job Description Example
Our company is hiring for an appeals supervisor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals supervisor
  • Manage Administrative Law Judge (ALJ) activities for Part C including participating in hearings as necessary
  • Ensures coverage dispute reconsideration meet applicable quality standards
  • Reviews and Updates Part C specific Policy materials as appropriate and documents
  • Represents the Part C QIC on the QIC Change Control Committee
  • Key participant in CMS Medical Forums and Project Audits
  • Participates in ALJ (Administrative Law Judge) hearings to explain and defend reconsideration decisions
  • Responds to outside inquiries of concerns regarding decided reconsidered determinations
  • Performs special projects not related to a specific case such as general legal research
  • Daily operational oversight, staff development, budget management, audit readiness, staff training documentation and execution and policy and procedure documentation
  • Work with internal partners and the PA staff to ensure ability to service physicians, pharmacists and patients within service levels and provide for appropriate clinical drug therapies
Qualifications for appeals supervisor
  • 1 or more years of clinical appeals experience
  • Bachelor Degree and 2 years business experience OR 6 years business experience
  • 3 years appeals review experience
  • Unrestricted, current Registered Nurse licensure required
  • Minimum five years of progressively responsible experience in an acute care/clinical setting, including utilization management, case management, appeals and/or discharge planning
  • Three years of experience within utilization management in a managed care organization required

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