Manager Appeals & Rebuttals - Remote

Manager Appeals & Rebuttals

ARC Group has an immediate opportunity for Manager Appeals & Rebuttals! This position is 100% remote working Eastern time zone business hours. This is a direct hire FTE position and is a fantastic opportunity to join an established and well-respected organization offering tremendous career growth potential. Salary, bonus potential, excellent benefits package! At ARC Group, we are committed to fostering a diverse and inclusive workplace where everyone feels valued and respected.

We believe that diverse perspectives lead to better innovation and problem-solving. As an organization, we embrace diversity in all its forms and encourage individuals from underrepresented groups to apply.

100% REMOTE! Candidates must have permanent work authorization and work for any employer without sponsorship now or in the future. Third party candidates are not eligible for this role.

Responsible for providing leadership and direction of all Provider/Supplier Enrollment appeal (CAPs/reconsiderations) and rebuttal operations, utilizing analytical skills and regulatory knowledge to ensure timely and compliant adherence with all Provider Enrollment appeal and rebuttal contractual obligations, CMS program guidance and departmental procedures. This includes leading, managing, and providing direction for all appeals activities and rebuttal processes. This position does not interpret statutes or regulations for the purpose of providing legal advice and does not act as an attorney for the organization.

The Appeals Manager provides direct leadership and management for lower-level exempt and higher-level non-exempt individual contributors.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This list of essential job functions is not exhaustive and may be supplemented as necessary.

Leadership, Operations, and Compliance (70%) Accountable for the oversight and effective management of all appeals and rebuttals. The department is responsible for responding to all requests expressing dissatisfaction with the initial provider/supplier enrollment determinations:

• Lead, direct and manage the daily operations of the Durable Medical Equipment, Prosthetics, Orthotics and Suppliers (DMDPOS) appeals and rebuttals, including workflow management, quality review and staff development.
• Ensure appeal decisions are consistent with federal regulatory requirements, contractual obligations and CMS program guidance.
• Accountable for reviewing and operationalizing requirements outlined in Technical Direction Letters (TDLs), Change Requests (CRs), the Statement of Work (SOW), and the Medicare Program Integrity Manual (PIM) and ensuring their timely and accurate implementation across all enrollment functions.
• Review complex appeal cases to assess facts, apply existing policies and guide consistent outcomes.
• Identify trends, risks and process improvement opportunities and escalate matters appropriately.
• Serve as a key liaison and partner to internal and external legal counsel, contributing to case strategy, documentation standards, administrative record development, and supports decision-making by identifying risks and operational impacts.
• Interact with the Centers for Medicare & Medicaid Services (CMS) and the Office of the General Counsel (OGC), as requested by CMS, to timely and accurately adjudicate provider/supplier enrollment initial determinations, deactivations, and stays of enrollment that may be appealed or rebutted.
• Review and process appealable determinations (such as denial of billing privileges, revocation of existing billing privileges, and effective date determinations and rebuttable determinations (such as deactivation of billing privileges and the application of stays of enrollment) in accordance with applicable CMS program guidance.
• Coordinate with CMS and internal stakeholders to ensure appeals are supported with complete documentation, clear rationale, and consistent application of regulatory requirements.

Appeal and Rebuttal Strategy and Risk Mitigation (15%)

• Lead the appeals (CAP/reconsideration) rebuttal strategy
• Ensure appeals (CAP/reconsideration) and rebuttal narratives are supported by evidence, policy, and regulatory requirements.
• Establish and maintain processes and workflows that ensure appeals and rebuttals are handled timely and accurately.
• Identify trends in rebuttal and appeals that can be incorporated into training, policy updates, and process redesign

Cross-Functional Collaboration and Process Improvement (15%)

• Serve as subject matter expert and primary escalation contact for internal leaders, external partners, and regulatory bodies
• Collaborate with Legal to ensure clear and accurate interpretation of regulatory authority and CMS guidance, where appropriate.
• Support cross-functional initiatives to reduce appeal and rebuttal volume through upstream…