Supervisor Appeals - Medicare

This role supervises the Part A and/or Part B Medicare Fee-for-Service appeals unit within the Organization's Medicare Services. The incumbent delegates assignments to appeal representatives and technical staff, manages resources to meet CMS thresholds and internal customer standards, and assists with budget preparation and performance monitoring. Responsibilities include ensuring compliance with corporate and CMS requirements, overseeing non-clinical staff determinations, and communicating with external entities such as CMS, OIG, and appellants.

Responsibilities

• Display effective verbal and written communication with internal leadership, peers, staff, external partners (e.g., PSC, RAC, QIC), and customers (e.g., CMS, providers, beneficiaries).
• Contribute to department performance standards, budget adherence, and CMS program memoranda.
• Delegate work assignments, monitor inventory, and manage resources to meet CMS thresholds.
• Ensure compliance with management controls, process quality plans, change requests, and internal/external audits.
• Document department protocols and controls; identify opportunities for performance improvement.
• Assist in guideline and procedural development in accordance with CMS instructions.
• Utilize technology to monitor departmental inventories and workflows.
• Provide direct oversight and/or technical direction to processing staff making pay/deny decisions.
• Coordinate provider education activities and maintain responsibility for personnel matters (hiring, performance appraisals, corrective action).
• Sustain production and quality levels; ensure staff receive refresher/remedial training and coaching.
• Manage high-profile or irate provider situations; coordinate responses with operational units or partners.
• Detect, investigate, and analyze problems in Medicare claims processing and departmental procedures.
• Recommend and initiate process improvements for efficiency, cost reduction, and quality gains.
• Support or direct projects aligned with organizational priorities.
• Provide recommendations to management impacting departmental efficiency and performance.
• Adhere to all applicable laws, regulations, and company policies (e.g., HIPAA, data security).

Requirements

• Minimum: High School diploma or GED.
• 1–3 years of experience in a leadership/supervisory position.
• Preferred: Bachelor’s degree and 3 years of healthcare industry experience or Associate’s degree and 5 years of healthcare industry experience.

Skills

• 1–3 years of experience working in the Medicare Program or with Medicare regulations.
• 3–5 years of experience using Microsoft Windows or similar environments.
• Experience with claims processing systems (e.g., MCS/FISS).
• Strong verbal and written communication skills for internal and external stakeholders.
• Ability to multitask under pressure with tact, diplomacy, and professionalism.
• Commitment to ethical decision-making, compliance, and organizational core values.
• Accountability for quality and process improvement initiatives.
• Must meet all CMS and organizational security requirements.

Pay

Base pay range: $62,700.00 – $97,200.00. Compensation is determined by qualifications, experience, internal peer equity, market factors, and business considerations. Geographic differentials may apply for certain locations.

Schedule

This is a full-time, non-travel position with direct supervision of approximately 30 employees.