Supervisor, Denial & Appeals- Care Coordination, Full-Time, Mullica Hill

MAJOR FUNCTION:

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.

QUALIFICATION:

Education & Experience:

• BSN required; MSN preferred.
• Registered Nurse licensure required.
• Prior supervisory/charge/lead experience (formal or informal) preferred.
• 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.     

Certification/Licensure:  

• Registered Nurse License Required.
• MCG Certification Preferred. 
• Case Management Certification Preferred.

Knowledge & Skills:

• Demonstrates role-modeling behavior through professional and effective interpersonal communication with staff and external stakeholders.
• Ability to work independently and set priorities efficiently under constraints of managed care guidelines.
• Ability to coordinate, compile, and analyze data. Maintain denial tracker and UM report (LOS, denial rate, turn around times, UM outliers).
• 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.

  BENEFITS INFORMATION:

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At Inspira Health, you’ll join with the area’s most dedicated and distinguished team to bring quality and compassionate care to our communities. We focus on clinical excellence, providing evidence-based care to help each patient achieve the best possible outcome. The scope and depth of our network can open many doors for your learning and career growth.

Our charitable nonprofit health care organization serves communities across southern New Jersey. The network, which traces its roots to 1899, comprises three hospitals, a comprehensive cancer center, sleep medicine, cardiac testing, digestive health and wound care, urgent care, imaging and rehabilitation, and primary and specialty physician practices in Gloucester, Cumberland, Salem and Camden counties.

Inspira is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, religion, creed, color, national origin, ancestry, age, marital status, affectional or sexual orientation, familial status, disability, liability for service in the Armed Forces of the United States, nationality, sex, gender identity or expression.