• Medical Necessity Appeals Manager

    Job Locations US-MO-Chesterfield
    Job ID
    # of Openings
    Hidden (22620)
  • Overview


    Patient Minded I act with the patient’s best interest in mind.

    Client Delight I own every client experience and its impact on results.

    Take Action I am empowered and empower others to act now.

    Grow Talent I own my development and invest in the development of others. 

    Win Together I passionately connect with anyone, anywhere, anytime to achieve results.

    Communication Matters I speak up to create transparent, thoughtful and timely dialogue.

    Own It I hold myself and others accountable for results.



    The Medical Necessity Appeals Manager will serve as the subject matter expert for the medical necessity appeals process and is responsible for guiding and overseeing the Clinical Appeals Nurses and Clinical Navigation Resource Coordinator to ensure the highest quality Medical Necessity Appeals services to the patients of the clients we serve.  The Medical Necessity Appeals Manager will collaborate to develop appropriate best practices and quality initiatives that include data collection, trending, analysis and reporting to ensure ongoing process improvements and client delight, and  to ensure that all appeals efforts are carried out in a compliant manner with state and federal guidelines. 



    Our people leaders are tasked with delivering excellent business results through the efforts of their teams.  These results are achieved by:


    • Setting clear direction, effective plans and measurable outcomes
    • Ensuring work is accomplished effectively by managing employee performance, work processes and other resources
    • Engaging employees to maximize their discretionary effort
    • Developing a pipeline of excellent talent to fill future business needs


    People leaders must possess both the skills to effectively accomplish these tasks and the emotional intelligence to do so in alignment with our cultural values.  In addition to the critical management and leadership tasks listed above, this role also includes the following unique responsibilities:



    • Understanding of Commercial and Government payer processes, prior authorization and appeals processes, clinical criteria, payer guidelines and medical necessity appeals processes
    • Facilitate the delivery of best in class services
    • Ongoing collection of pertinent data while analyzing, aggregating and evaluating for trends to ensure continual quality improvement efforts and collaborate with colleagues and leadership to promote accurate client data reporting
    • Promote client satisfaction by ensuring compliance to program services, policies and contractual obligations


    essential duties and responsibilites:

    • Supervise a team of Clinical Appeals Nurses who are responsible for the timely submission of appeals on behalf of the patients for new and active patients
    • Ensure the team of Clinical Appeals Nurses works within their scope of practice
    • Collaborate with the Medical Necessity Appeals team to ensure delivery of quality patient services
    • Conduct hiring, training, evaluation and ongoing development of staff
    • Establish workflow, work methods and performance standards for the team
    • Participate in developing standards and best practice guidelines based on client delight and regulatory and compliance standards
    • Participate and contribute in staff meetings and patient care conferences
    • Serve as a point of escalation for calls requiring a higher degree of expertise or discretion to resolve customer issues or complaints
    • Travel may be required to attend meetings or conferences

    The above list reflects the general details necessary to describe the principle and essential functions of the position and shall not be construed as the only duties that may be assigned for the position.


    An individual in this position must be able to successfully perform the essential duties and responsibilities listed above. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.


    MINIMUM qualifications:

    The requirements listed below are representative of the experience, education, knowledge, skill and/or abilities required.


    • Bachelor’s Degree in Nursing
    • Current MO RN license in good standing
    • Six years of relevant clinical experience
    • Two years supervisory/management experience
    • Knowledge of third party payer regulations relate to utilization and quality review
    • Analytical, creative and interpersonal skills essential


    • Demonstrated proficiency in Microsoft Office applications
    • Strong written, verbal, and interpersonal skills
    • Professional behavior, demonstrates integrity, credibility, high moral and ethical behavior
    • Demonstrated leadership through confidence in decision making and empathy for employees and customers
    • Ability to inspires others to deliver and is accountable for results
    • Ability to create a climate that motivates and encourages others to participate
    • Commitment to teamwork


    Preferred qualifications:

    • Upbeat attitude, a genuine interest in others and a sense of humor
    • Ability to energize others and heighten morale through her/his attitude
    • Transforms creative ideas into original solutions that positively impact the company’s performance



    This is a largely sedentary role.  While performing the duties of this job, the employee is regularly required to talk, hear, type and engage in repetitive motion. 


    The employee frequently is required to walk; use hands to finger, handle or feel; and reach with hands and arms.  The employee is occasionally required to stand or grasp. The employee is intermittently required to stoop or crouch; push or pull; or kneel. 


    The employee must occasionally lift and/or move up to 10 pounds and intermittently lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.


    This role requires mental alertness. The employee must regularly communicate both verbally and written; concentrate on tasks; and remember and observe details. The employee must frequently adjust to changes; handle stress and emotions; and think analytically.


    The mental and physical requirements described here are representative of those that must be met by an individual to successfully perform the essential functions of this position.


    Working ENVIRONMENT:

    This job operates in a professional office environment. This role routinely uses standard office equipment. The noise level in the work environment is usually moderate.  The employee is not substantially exposed to environmental conditions.


    The work environment characteristics described here are representative of those an individual encounters while performing the essential functions of this position.




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