Clinical Adjudication Supervisor

Job Summary

Providing oversight and independent decision-making, the Clinical Adjudication Supervisor will manage appeals and dispute resolutions for patient and provider cases during weekday evening shifts, with flexible scheduling available in a remote capacity.

Key responsibilities

• Oversees formal discussions with appellants/requestors/providers to gather additional documentation and clarify appeal issues
• Reviews medical records and writes clear, concise reconsiderations that support determinations made
• Makes independent decisions based on medical evidence, ensuring compliance with relevant statutes and regulations

Required qualifications

• Associate's degree or 60+ credit hours towards a Bachelor's degree in healthcare or related discipline, or equivalent experience
• Five years of experience in Medicare appeals, medical review, or utilization management of Medicare claims
• Supervisory or Team Lead experience in a healthcare setting
• Experience in writing or overseeing Medicare-related medical necessity decisions
• Background in Nursing, Physical Therapy, Respiratory Therapy, or Occupational Therapy preferred