Mayo Clinic
Director of Clinical Appeals
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 include: Leading the strategic direction and execution of the clinical appeals process across Mayo Clinic locations. Managing a high-performing team of nurse reviewers, clinical appeal writers, and support staff. Overseeing appeal letter development, clinical justification protocols, and compliance with payer and regulatory guidelines. Analyzing trends in clinical denials to inform mitigation strategies and improve first-pass claim performance. Collaborating closely with Utilization Review, Care Management, Compliance, Legal, and Payer Relations to enhance outcomes. Ensuring all appeal processes meet state and federal regulations, including Medicare and Medicaid. Identifying and implementing technologies and workflows to improve turnaround time and win rates. Developing and monitoring 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. Master's 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). Bachelor's degree in Nursing (BSN); Master's 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. Exemption Status: Exempt Compensation Detail: $160,076 - $232,107 / year Benefits Eligible: Yes Schedule: Full Time Hours/Pay Period: 80 Schedule Details: Monday - Friday; 8:00 am - 5:00 pm Weekend Schedule: N/A International Assignment: No Site Description: Each Mayo Clinic location is a special place where our employees thrive in both their work and personal lives. Equal Opportunity: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, protected veteran status or disability status.
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 include: Leading the strategic direction and execution of the clinical appeals process across Mayo Clinic locations. Managing a high-performing team of nurse reviewers, clinical appeal writers, and support staff. Overseeing appeal letter development, clinical justification protocols, and compliance with payer and regulatory guidelines. Analyzing trends in clinical denials to inform mitigation strategies and improve first-pass claim performance. Collaborating closely with Utilization Review, Care Management, Compliance, Legal, and Payer Relations to enhance outcomes. Ensuring all appeal processes meet state and federal regulations, including Medicare and Medicaid. Identifying and implementing technologies and workflows to improve turnaround time and win rates. Developing and monitoring 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. Master's 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). Bachelor's degree in Nursing (BSN); Master's 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. Exemption Status: Exempt Compensation Detail: $160,076 - $232,107 / year Benefits Eligible: Yes Schedule: Full Time Hours/Pay Period: 80 Schedule Details: Monday - Friday; 8:00 am - 5:00 pm Weekend Schedule: N/A International Assignment: No Site Description: Each Mayo Clinic location is a special place where our employees thrive in both their work and personal lives. Equal Opportunity: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, protected veteran status or disability status.