Independence Blue Cross LLC
Philadelphia, PA, USA
The Manager, Clinical Appeals (RN) leads the end-to-end clinical appeals function for both member and provider appeals, ensuring decisions are clinically sound, timely, defensible, and fully compliant with applicable federal, state, and accreditation requirements. This role oversees RN reviewers and clinical staff, manages vendor/peer review workflows, and partners cross-functionally (Medical Directors, Compliance, Legal, UM, Customer Service) to optimize outcomes, reduce overturn rates, and deliver an excellent member and provider experience. Key Responsibilities Operational Leadership · Manage day-to-day operations of the clinical appeals team (RN reviewers, coordinators), including staffing, workload distribution, case assignment, and escalation management. · Ensure timely completion of appeals within regulatory and contractual turnaround times for all lines of business. · Oversee the clinical development of appeal rationales,...