Director Clinical Appeals
Director Clinical Appeals
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Job Description
The Director reports to the Sr. Director Revenue Cycle and may have Revenue Cycle Managers and other Revenue Cycle staff as direct reports in a multi-site multi-specialty academic medical center Assures the integrity and stability of revenue and billing data and provides direction for complex business decision making for operations. Provides direction for complex business decision making for operations. Identifies establishes and implements internal controls to ensure a compliant environment. Provides leadership in a team environment teams functional and technical activities and changes.. Participates in establishing the strategic direction of work teams or service lines incorporating an awareness of the internal and external environment. Provides direction and interprets revenue cycle key performance indicators with significant institutional impact Is recognized and relied upon to synthesize various subject matter expert inputs to formulate solutions and implement change for multi-disciplinary or complex technical issues. Coordinates the development of programs and processes for Revenue Cycle operational areas. Interprets and implements billing rules regulatory compliance policies and regulations. Stays abreast of emerging issues and risks and plans accordingly. Identify strategies that lead to improved financial performance and follow through on their implementation while preserving Mayo standards and minimizing the financial and legal risks to Mayo. Directs managers reviews and interprets results of variable-sensitive business models and/or compliance or business operations. Participates in establishing an environment that leads to efficient Revenue Cycle operations and adheres to complicated and ambiguous billing rules and regulations (all payers). Responsible for recruitment development and performance management within areas of responsibility translating the departmental vision into meaningful and effective results. Spearheads change and leads others in implementation. Promotes effective change management practices. Initiates leads and facilitates institutional workgroups or complex projects. Manages and prioritizes limited resources across multi-disciplinary multi-site teams to maximize efficiency. Handles ambiguous situations in a productive and professional manner and leads others through such situations successfully. Travel required as assignments warrant.
Position Overview
The Director of Clinical Appeals will serve as a strategic and operational leader within the Revenue Cycle Department. This role is responsible for overseeing the clinical appeals program across the Mayo Clinic enterprise driving performance compliance and outcomes related to clinical denials and appeals. You will lead a team of clinicians and appeal specialists interfacing with payers compliance utilization review legal and clinical departments.
This is a critical leadership role where clinical judgment revenue cycle acumen and operational leadership intersect.
Key Responsibilities
- Lead the strategic direction and execution of the clinical appeals process across Mayo Clinic locations.
- Manage a high-performing team of nurse reviewers clinical appeal writers and support staff.
- Oversee appeal letter development clinical justification protocols and compliance with payer and regulatory guidelines.
- Analyze trends in clinical denials to inform mitigation strategies and improve first-pass claim performance.
- Collaborate closely with Utilization Review Care Management Compliance Legal and Payer Relations to enhance outcomes.
- Ensure all appeal processes meet state and federal regulations including Medicare and Medicaid.
- Identify and implement technologies and workflows to improve turnaround time and win rates.
- Develop and monitor KPIs dashboards and reporting for internal stakeholders and senior leadership.
During the selection process you may participate in an OnDemand (pre-recorded) interview that you can complete at your convenience. During the OnDemand interview a question will appear on your screen and you will have time to consider each question before responding. You will have the opportunity to re-record your answer to each question - Mayo Clinic will only see the final recording. The complete interview will be reviewed by a Mayo Clinic staff member and you will be notified of next steps.
Qualifications
Bachelor degree with 10 years experience which includes at least 7 years in general leadership required. Masters degree preferred.
Broad expertise in healthcare management healthcare operations change management and systems preferred. Possesses and applies knowledge of healthcare clinical and administrative systems and processes to achieve organizational priorities. Has solid knowledge of Microsoft applications including Word Excel PowerPoint and Outlook. Possess ability to apply broad knowledge to new circumstances to add value and perspective. Exhibits a customer-service orientation; anticipates understands and addresses customer needs in a timely manner. Working knowledge of large revenue cycle systems preferred and medical record systems. Ability to establish a productive team-based work environment and collaborate effectively across multiple sites and functions. Demonstrated communication and presentation skills. Ability to lead or direct multiple complex projects and activities in an ambiguous environment. Participates in establishing an environment that promotes initiative creativity and a high level of productivity. Healthcare Financial Management Association (HFMA) Certification Preferred.
Preferred Qualifications:
- Current Registered Nurse (RN) license in the United States (multi-state compact license or eligibility in Minnesota preferred).
- Bachelors degree in Nursing (BSN); Masters degree in Nursing Health Administration or related field strongly preferred.
- 7 years of clinical experience with 5 years in case management utilization review or clinical denials/appeals.
- 3 years of leadership experience in a hospital or health system setting.
- In-depth understanding of payer guidelines regulatory compliance and the revenue cycle.
- Demonstrated success in team building cross-functional collaboration and strategic execution.
- Experience in an academic medical center or large health system.
- Certification in Case Management (CCM) Utilization Review (URAC) or Healthcare Quality (CPHQ).
- Working knowledge of Epic Midas or similar EHR/utilization management systems.
Authorization to work and remain in the United States without necessity for Mayo Clinic sponsorships now or in the future (for example be a U.S. Citizen national or permanent resident refugee or asylee). Mayo Clinic does not participate in the F-1 STEM OPT extension program.
Required Experience:
Director
Employment Type
Full-Time
