Senior Director of Provider Appeals

A company is looking for a Senior Director, Provider Appeals.

Key Responsibilities

Develop and maintain the strategic roadmap for the provider appeals program, ensuring compliance with regulatory requirements

Oversee daily operations and staff management of provider appeals, ensuring timely resolution within mandated timeframes

Ensure compliance with CMS regulations and maintain audit-ready documentation practices

Required Qualifications and Education

7+ years of experience in appeals, utilization management, claims review, or clinical adjudication

Deep understanding of CMS Medicare Advantage Part C requirements and appeal decision standards

Bachelor's degree in Healthcare Administration, Business, or a related field

Experience in case review and writing defensible rationales

Preferred : Master's degree