Director Pre Appeals Management-HSO… at Mount Sinai… · New York

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 experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $153723 - $230584 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.