We are seeking an experienced and dynamic professional for the role of Strategic Appeals Manager. This full-time position is based in Lake Forest, CA, with potential for hybrid or remote work for exceptional candidates. This role offers competitive remuneration, equity, comprehensive benefits, and significant growth prospects.

The Strategic Appeals Manager plays a critical role in managing and optimizing the appeals process to maximize reimbursement and minimize denials. The role requires a blend of clinical expertise, in-depth understanding of payer policies, analytical skills, and cross-functional leadership to oversee complex appeals across various business lines.

Key Responsibilities

• Identify and analyze payer trends and root causes of denials, translating findings into actionable solutions.
• Oversee and strategize complex appeals, including medical necessity, coding, and authorization issues.
• Develop and maintain updated appeal packages aligned with current clinical guidelines, legislation, and payer policies.
• Interpret and apply clinical guidelines, payer medical policies, and regulatory requirements.
• Collaborate with internal and external stakeholders to ensure comprehensive clinical documentation supports appeal submissions.
• Track and report on appeal success rates, turnaround times, and ROI.
• Manage day-to-day appeal operations, ensuring compliance with regulatory and payer requirements.
• Train teams on best practices and payer nuances, providing ongoing education on denial trends.
• Influence process improvements to reduce repeat denials.

Required Qualifications

• Bachelor’s degree in Healthcare Administration, Nursing, Health Information Management, or a related field (Master’s preferred).
• Minimum of 5 years' experience in healthcare revenue cycle, appeals, or payer relations, preferably within the diagnostic space.
• Proven success in leading complex medical necessity and policy-based appeals.
• Strong knowledge of ICD-10-CM, CPT/HCPCS, CMS rules, and payer policies.
• Experience with external reviews, ALJs, or arbitration is advantageous.
• Familiarity with denial management systems and analytics tools.

Key Competencies

• Strategic thinking and payer knowledge.
• Clinical and regulatory interpretation skills.
• Strong analytical and problem-solving abilities.
• Effective verbal and written communication skills.
• Excellent organizational and time management skills with the ability to manage multiple tasks.
• Data-driven decision-making capabilities.
• Executive-level communication and influence.
• Proficiency in process improvement and change leadership.

This role presents an exciting opportunity to join a fast-paced, innovative team dedicated to making a significant impact in healthcare. If you're passionate about driving results and influencing change, we encourage you to apply.