MAJOR FUNCTION:

The Denial and Appeals Supervisor provides operational and clinical oversight for the utilization review, utilization management, denial prevention, denial management, and appeals functions within Care Coordination. This role supervises day-to-day workflows, monitors timeliness and quality standards, identifies and reports denial trends, and escalates complex payer issues as needed. Serves as a liaison between care coordination staff, payers, and internal physician advisors to ensure compliant, effective utilization management and appeal submissions. Collaborates with internal and external stakeholders to ensure compliance with state and national rules and regulations, payer contracts, and organizational policy; supports staff development through coaching, training, and performance feedback while maintaining clinical competency and current knowledge of regulatory and payor requirements.

QUALIFICATION:

Education & Experience: