Director, Appeals

Role Overview

• 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 our 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

• 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
• Commitment to diversity, philanthropy and sustainability
• Modern workplace with casual dress code, open floor plans, full-service dining, free snacks and drinks, complimentary 24/7 fitness center with group classes, outdoor walking paths, game room, notary and dry-cleaning services