Supervisor, Denial & Appeals- Care Coordination, Full-Time, Vineland

Inspira Health•Vineland, NJ

2d•$46 - $63•Onsite

About The Position

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.

Requirements

BSN required
Registered Nurse licensure required
Minimum of 3 years clinical nurse experience
Minimum of 3 years of utilization review experience required
Minimum of 2 years recent case management experience required
Ongoing experience with payer portals and provider manuals as well as CMS regulations
Registered Nurse License Required
Must have knowledge and understanding of Centers for Medicare &Medicaid Services (CMS) guidelines and Conditions of Participation.
Ability to work independently and set priorities efficiently under constraints of managed care guidelines.
Ability to coordinate, compile, and analyze data.
Excellent communication skills (oral and written) and interpersonal skills necessary to negotiate with families, patients, post-acute providers and third-party payors.
Understanding of payer portals and provider manuals.

Nice To Haves

MSN preferred
Prior supervisory/charge/lead experience (formal or informal) preferred
MCG Certification Preferred
Case Management Certification Preferred

Responsibilities

Provides operational and clinical oversight for utilization review, utilization management, denial prevention, denial management, and appeals functions within Care Coordination.
Supervises day-to-day workflows.
Monitors timeliness and quality standards.
Identifies and reports denial trends.
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.
Maintains clinical competency and current knowledge of regulatory and payor requirements.
Maintains denial tracker and UM report (LOS, denial rate, turn around times, UM outliers).