Claims Appeals Manager
1 week ago
NaphCare has an excellent opportunity for a Claims Appeals Manager to join our Corporate Office in Birmingham, AL.
The Claims Appeals Manager will lead the provider appeals and dispute resolution process related to medical claims processing and payments. This role is responsible for managing a team that handles provider appeals regarding denied, reduced, or adjusted claims. The ideal candidate will ensure appeals are processed accurately, timely, and in compliance with client policy, provider contracts, and regulatory guidelines while maintaining strong provider relationships.
ResponsibilitiesKey responsibilities include and may not be limited to:
- Oversee the day-to-day management of the claim's appeals team, ensuring timely and accurate resolution of all claim disputes.
- Review complex appeal cases, including escalated provider disputes, provider refunds, vendor negative balances; provide resolution recommendations based on client policy, provider contracts, authorized services and claim edits.
- Ensure appeals processing complies with company policies, contracts; state and federal regulations.
- Lead and mentor claims analysts and specialists to ensure quality, efficiency, and consistency in adjudicating appeals.
- Collaborate closely with external departments, including Contracting, Operations, Legal and Provider Relations to clarify policy interpretation and resolve complex disputes.
- Track, analyze, and report on key appeals metrics such as volume, turnaround time, overturn rates, and root cause analysis of adjustments.
- Analyze appeal trends, identify root causes and recommend process improvements to reduce appeal volume.
- Communicate clearly and professionally with providers regarding appeals outcomes and procedural guidelines.
- Stay current on industry trends, CMS-Medicaid policies and best practices for claims appeals management.
- Support audit and compliance activities related to appeals workflows and documentation.
- Bachelor's degree in Healthcare Administration, Business, or a related field required.
- Advanced degree or certification (e.g., CPC, CPMA) a plus.
- 5+ years of experience in healthcare claims or appeals, with at least 2 years in a supervisory or management role.
- Strong understanding of provider contracts, claims adjudication systems, medical billing/coding (CPT, HCPCS, ICD-10) and medical terminology.
- Strong understanding with payer regulations including CMS and Medicaid guidelines, ERISA, and regulatory industry standards.
- Proven leadership and team development skills.
- Excellent analytical, organizational, and decision-making abilities.
- Ability to interpret complex provider contracts and medical policies.
- Strong communication and negotiation skills to handle sensitive provider relations issues.
- Proficiency with claims adjudication systems, ticket systems and appeals management tools.
- High attention to detail and ability to work in a fast-paced, deadline-driven environment.
Working Conditions:
- Office-based
- Ability to manage workload during peak appeals periods or regulatory deadlines
Why Join NaphCare?
NaphCare is one of the largest providers of healthcare services to correctional facilities throughout the US and we are growing. If you have never considered a career in correctional healthcare, now may be the time. In addition to competitive salaries and generous employee benefits, we strongly support career advancement within the company.
NaphCare Benefits for Full-Time Employees Include:
- Health, dental & vision insurance that starts day one
- Prescriptions free of charge through our health plan, beginning day one
- Lowest Cost Benefits
- Employee Assistance Program (EAP) services
- 401K and Roth with company contribution that starts day one
- Tuition Assistance
- Referral bonuses
- Term life insurance at no cost to the employee
- Generous paid time off & paid holidays
- Free continuing education and CMEs
If you would like to speak with me to learn more about this position and NaphCare, apply directly to the position to initiate the application process, and I'll be in touch.
Equal Opportunity Employer: disability/veteran
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The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with a job.
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