Director Pre Appeals Management-HSO Appeals Management -Corporate 42nd Street-Full-Time-Days -Remote
Description Job Description Director Pre Appeals Management-HSO Appeals Management -Corporate 42nd Street-Full-Time-Days -Remote The Director, Pre Appeals Management is a strategic enterprise leader who provides strategic leadership and operational oversight for the hospital’s pre-appeals management program. This role ensures the appropriate use of medical resources, compliance with regulatory standards, and coordination of care to improve patient outcomes while controlling costs. The Director collaborates closely with medical staff, vendors, case management, and payers to secure payment and benefits for beneficiaries that is in alignment with the clinical care provided.
Responsibilities Lead and manage the pre appeals department and related vendors , including supervision of pre appeals nurses, and support staff.
Develop and implement pre appeals strategies, policies, and procedures to ensure regulatory compliance (CMS, The Joint Commission, NCQA, etc.).
Oversee daily pre appeals activities including admission and continued stay, and discharge reviews using CMS guidelines and payer contract terms.
Ensure timely and appropriate communication with payers for authorization, denials, and appeals.
Collaborate with physicians and clinical teams to ensure appropriate levels of care and efficient resource utilization.
Analyze utilization data and key performance indicators to identify trends, variances, and opportunities for improvement.
Serve as a liaison between hospital administration, payers, medical staff, and external partners.
Lead denial management and appeal processes to minimize revenue loss.
Conduct staff education and training on denial avoidance processes, documentation, and compliance.
Participate in hospital quality and performance improvement initiatives.
Maintain current knowledge of healthcare regulations, reimbursement models, and best practices. Manage departmental budget, staffing levels, and performance evaluations.
Key Outcomes Of Success
Enhanced patient satisfaction and financial transparency
Measurable reduction in clinical submission errors and denied level of care.
Alignment with organizational goals and regulatory requirements
Demonstrated leadership in enterprise-wide initiatives that advance access, equity, and financial stewardship Qualifications Bachelor?s degree in Nursing (BSN) or related healthcare field required Master?s degree in Nursing, Healthcare Administration, Business, or related field strongly preferred Licensure/Certification:
Active RN license in the state of employment required
Certification in Case Management (CCM, ACM) or Utilization Management preferred.
7+ years of experience in clinical acute clinical, utilization management, appeals management or related operations
3+ years in a leadership or management role
Strong understanding of payer policies, utilization management Skills & Competencies :
Proven ability to lead cross-functional teams and manage complex workflows
Strong analytical and problem-solving skills
Knowledge of relevant laws and regulations (e.g., HIPAA, CMS, utilization management standards)
Experience with EHR/EMR systems, payer portals, or access control tools
Excellent communication and interpersonal skills
Preferred Qualifications (Industry-Specific):
Healthcare: Experience with utilization management for medical services, procedures, or medications
Insurance: Understanding of benefits verification, coverage determination, or claims workflows
Fintech/IT: EPIC
Describe Work Environment Office-based May require occasional travel to regional offices or conferences Non-Bargaining Unit, 416 - HSO Appeals Management - MSH, Mount Sinai Hospital Employer Description Strength through Unity and Inclusion The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare.
We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.
At Mount
Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace ex
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Responsibilities Lead and manage the pre appeals department and related vendors , including supervision of pre appeals nurses, and support staff.
Develop and implement pre appeals strategies, policies, and procedures to ensure regulatory compliance (CMS, The Joint Commission, NCQA, etc.).
Oversee daily pre appeals activities including admission and continued stay, and discharge reviews using CMS guidelines and payer contract terms.
Ensure timely and appropriate communication with payers for authorization, denials, and appeals.
Collaborate with physicians and clinical teams to ensure appropriate levels of care and efficient resource utilization.
Analyze utilization data and key performance indicators to identify trends, variances, and opportunities for improvement.
Serve as a liaison between hospital administration, payers, medical staff, and external partners.
Lead denial management and appeal processes to minimize revenue loss.
Conduct staff education and training on denial avoidance processes, documentation, and compliance.
Participate in hospital quality and performance improvement initiatives.
Maintain current knowledge of healthcare regulations, reimbursement models, and best practices. Manage departmental budget, staffing levels, and performance evaluations.
Key Outcomes Of Success
Enhanced patient satisfaction and financial transparency
Measurable reduction in clinical submission errors and denied level of care.
Alignment with organizational goals and regulatory requirements
Demonstrated leadership in enterprise-wide initiatives that advance access, equity, and financial stewardship Qualifications Bachelor?s degree in Nursing (BSN) or related healthcare field required Master?s degree in Nursing, Healthcare Administration, Business, or related field strongly preferred Licensure/Certification:
Active RN license in the state of employment required
Certification in Case Management (CCM, ACM) or Utilization Management preferred.
7+ years of experience in clinical acute clinical, utilization management, appeals management or related operations
3+ years in a leadership or management role
Strong understanding of payer policies, utilization management Skills & Competencies :
Proven ability to lead cross-functional teams and manage complex workflows
Strong analytical and problem-solving skills
Knowledge of relevant laws and regulations (e.g., HIPAA, CMS, utilization management standards)
Experience with EHR/EMR systems, payer portals, or access control tools
Excellent communication and interpersonal skills
Preferred Qualifications (Industry-Specific):
Healthcare: Experience with utilization management for medical services, procedures, or medications
Insurance: Understanding of benefits verification, coverage determination, or claims workflows
Fintech/IT: EPIC
Describe Work Environment Office-based May require occasional travel to regional offices or conferences Non-Bargaining Unit, 416 - HSO Appeals Management - MSH, Mount Sinai Hospital Employer Description Strength through Unity and Inclusion The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare.
We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.
At Mount
Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace ex
Apply tot his job
Apply To this Job