Director, Appeals

About the role

The Director of Appeals leads and manages the clinical appeals function within the Utilization Management department. This role ensures timely, accurate, and clinically sound responses to appeals and grievances, while maintaining compliance with regulatory standards and payer requirements. The Director collaborates with internal and external stakeholders to optimize appeal outcomes and drive continuous improvement in clinical review processes.

Responsibilities

• 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.
• 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
• Able 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