Clinical Appeals Manager

Orthofix•Carlsbad, CA

4d•Onsite

About The Position

The Clinical Appeals Manager oversees and continuously improves Orthofix’s clinical appeals function. The role establishes standards, workflows, quality controls, and reporting processes that support effective reimbursement operations. Applying licensed clinical expertise and independent judgment, the manager evaluates payer denials, develops appeal strategies, and ensures compliant and timely submissions. The position works across functions to identify and address documentation, authorization, and reimbursement issues and to improve processes that reduce revenue risk and optimize reimbursement outcomes. The role leads the daily clinical appeals workflow, performs licensed clinical reviews, prepares or oversees patient-specific appeal narratives and complete appeal packages, and monitors payer-specific requirements, deadlines, aging, and outcomes. It establishes templates, checklists, documentation standards, quality controls, escalation rules, and an appeals dashboard, and communicates recurring issues to relevant owners. The manager collaborates with internal teams on case barriers and appeal readiness, supports permitted payer escalation and review activities, and provides practical education on clinical criteria and appeal requirements. The position also supports California DME licensure, inspection readiness, policy maintenance, and other clinical oversight assigned to the licensed professional. The position requires an active, unrestricted California RN or LVN license in good standing, graduation from an accredited nursing program, and at least six years of relevant experience. The employee must reside in California and work in the designated Orthofix California office; the position is not remote. Occasional business travel may be required, and regular attendance is required. The anticipated salary is $135,000 per year, plus a performance-based bonus and benefits.

Requirements

Active, unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license in California, maintained in good standing throughout employment.
Graduation from an accredited nursing program.
Current credentials and continuing education required to maintain California licensure.
At least six years of experience in clinical appeals, denials, utilization management, clinical review, case management, reimbursement, or a closely related healthcare function.
Experience reviewing medical records and applying payer coverage criteria, medical necessity requirements, and clinical documentation standards.
Demonstrated ability to write or critically review clear, accurate, and persuasive clinical appeal narratives.
Working knowledge of commercial, Medicare, and Medicaid payer processes, including appeal levels, filing requirements, authorizations, and medical necessity determinations.
Ability to manage multiple cases, competing priorities, deadlines, and escalations with attention to detail and follow-through.
Ability to distinguish clinical appeal issues from administrative, coding, billing, contracting, and legal issues and route matters to the appropriate owner.
Ability to lead a defined operational function, establish workflows, monitor quality, coach others, and report results without requiring Senior Manager or Director scope.
Excellent written and oral communication skills, including the ability to translate clinical and payer requirements for non-clinical audiences.
Sound judgment and commitment to patient privacy, confidentiality, compliance, and professional scope-of-practice boundaries.
Proficiency with Microsoft Word, Excel, PowerPoint, Outlook, and case-tracking or workflow systems.
Must reside in California and work in the designated Orthofix California office; the position is not remote.
Regular attendance is required.
Must be able to lift and transport products and literature to customer sites repetitively throughout each day, with lifting capacity of approximately 20 to 30 pounds.
Must travel by automobile and plane frequently.
Ability to use a PC or laptop computer and cell phone effectively.
Eyesight and hearing must be correctable to standard level.

Nice To Haves

Experience with durable medical equipment, bone growth stimulation, bracing, medical devices, home medical equipment, or another payer-intensive clinical environment.
Experience with clinical appeals involving medical necessity, prior authorization, experimental or investigational determinations, documentation deficiencies, or payer policy interpretation.
Experience building or improving an appeals workflow, work queue, quality review process, dashboard, or team structure.
Experience supporting payer audits, regulatory inspections, accreditation readiness, or corrective action activities.
Familiarity with California Medi-Cal and California managed care organizations.
Clinical background is a plus.
Experience in a medical device environment.

Responsibilities

Lead daily clinical appeals workflow, including intake, denial classification, eligibility review, prioritization, assignment, submission, follow-up, escalation, and closure.
Review payer denials and supporting records using licensed clinical judgment to identify clinical issues, documentation gaps, coverage requirements, and appropriate appeal pathways.
Develop or oversee accurate, patient-specific appeal narratives that connect clinical records, payer policy, medical necessity criteria, and supporting evidence without creating or altering treating-provider documentation.
Compile complete appeal packages with required clinical records, orders, certificates, payer correspondence, authorization records, policy excerpts, and other documentation.
Monitor payer filing deadlines, appeal levels, submission requirements, case aging, and status to reduce untimely or incomplete submissions.
Establish standardized appeal templates, evidence checklists, case documentation standards, quality controls, and escalation rules.
Create and maintain an appeals dashboard tracking volume, aging, submission timeliness, overturn outcomes, denial categories, payer trends, and dollars recovered or preserved.
Identify recurring clinical, documentation, policy, authorization, coding, or process issues and communicate findings to the appropriate functional owner.
Partner with the Senior Manager, Payer and Documentation Audits on documentation trends, audit support, and opportunities identified through appeals, while preserving that function’s ownership of audit strategy and enterprise revenue leakage initiatives.
Collaborate with Sales Administration, Accounts Receivables, Payer Contracting, Legal, Compliance, Medical Affairs, Sales, and field teams to resolve case-specific barriers and improve appeal readiness.
Support payer escalations, reconsiderations, peer-to-peer preparation, administrative hearings, and external reviews as permitted by applicable law, payer rules, and professional scope of practice.
Provide internal stakeholders with education and feedback on payer clinical criteria, medical necessity documentation, common denial drivers, and appeal package requirements.
Support California DME licensure, inspection readiness, policy maintenance, and other clinical oversight activities assigned to the licensed professional for the California office.
Maintain current knowledge of payer policies, Medicare and Medicaid requirements, California requirements, company policies, and professional licensure obligations.
Maintain regular and reliable attendance at the designated Orthofix California office.
Perform other duties as assigned.