Manager, Clinical Appeals – Grievances

. Manage and monitor appeal inventory for a team of Appeals & Grievances Clinical Specialists .

Posted 9/25/2026full-timeRemote • New York • United StatesMid-LevelSenior💰 $88,700 - $131,920 per yearWebsite

Key responsibilities & impact

Manage and monitor appeal inventory for a team of Appeals & Grievances Clinical Specialists
Prepare and plan weekend staff assignments and volume to ensure compliance
Triage and assign expedited appeals and optimize appeals and grievances routing
Manage weekend inventory to ensure regulatory compliance
Communicate and escalate cases to Medical Peer reviewers
Maintain delegated vendor relationships and monitor vendor performance and compliance
Coordinate with outside departments for case escalation, clarifications and appeal resolution
Manage letter review and printing and coordinate expedited printing with the mailroom
Review case change requests and cancellations and route follow-up appropriately
Review and submit Level 2 appeals packets
Maintain knowledge of industry trends, best practices and protocols and share enhancements across enterprise units
Identify trends and recommend improvement solutions
Deploy approaches to meet production, compliance and quality targets
Build partnerships across and outside operations to improve communication and responsiveness
Provide feedback and recommendations to leadership concerning staff performance
Comply with HIPAA and maintain confidentiality
Adhere to state and federal compliance and regulatory guidelines
Perform additional duties as assigned

What you’ll need

H.S. Diploma or GED
Proven work experience with appeals and grievances or in a healthcare environment
Work experience demonstrating verbal and written communication skills
Experience working independently in a fast-paced environment handling multiple priorities simultaneously
Willing and able to work a weekend schedule (Fri-Mon or Thurs-Sun)
Experience using Microsoft Word and Excel, corporate email, virtual filing systems such as Macess, and care management systems such as CCMS, TruCare and Hyland
Preferred: Bachelor’s degree
RN or LPN strongly preferred
Preferred experience in clinical practice, appeals and grievances, claims processing, utilization review or utilization/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines

Comp & perks