Supervisor, Medicare Appeals
TMF Health Quality Institute - San Antonio, TX

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TMF Health Quality Institute


Expectation for All Employees
Support the organization’s mission, vision and values by exhibiting the following behaviors: model integrity, embrace innovation, celebrate success, strive for excellence, focus on those we serve and foster trust.

Job Purpose
Support the Medicare Appeals team by serving as supervisor of review coordinators including acting as subject matter expert for appeal reviews. Assist in tracking and monitoring reviewer productivity, training of new personnel, performing quality assurance audits and completing employee performance evaluations. Perform medical record review as required by contracts. Manage review caseload. Coordinate with customer and staff.

Job Duties

  • Serve as clinical and technical resource for other staff members.
  • Assist in quality assurance assessment including preparation of reports as required per contract.
  • Assist in training and serve as preceptor for new employees.
  • Assist in daily work assignment for review staff.
  • Assist in tracking and monitoring of reviewer productivity to assure adherence to timelines and productivity goals.
  • Perform various types of medical record review by specific contracts including, but not limited to, first and second level appeal review.
  • Complete review of cases in accordance with guidelines and regulations.
  • Provide a fair and impartial decision.
  • Write clear and concise letters that support determination made.
  • Apply approved state and national criteria in determining medical necessity for healthcare services.
  • Prepare correspondence to healthcare providers, physicians and/or beneficiaries using proper grammar, the appropriate template and including all required components..
  • Document and track case review activities and case disposition within required time frames.
  • May serve as point of contact in working with customer to resolve issues related to systems access.
  • Use computers to enter, access or retrieve data.
  • Assist in identifying the best methods and most efficient approaches to determine areas of program improvement.
  • Identify and resolve problems or refer issues appropriately.
  • Communicate effectively with internal and external customers.
  • Adapt to the needs of internal and external customers.
  • Assure compliance with regulatory, contractual and accreditation entities.
  • Maintain strict adherence to confidentiality and security policies and procedures.
  • Participate in special projects and perform other duties as assigned.

Work Context
Requires sitting; Requires standing; Requires walking; Requires bending, twisting or reaching; Requires using hands to handle, control, or feel objects, tools or controls; Requires repetitive movement; Requires typing; Requires use of electronic mail; Requires writing letters and memos; Requires contact with others (face-to-face, by telephone, or otherwise); Requires work with others in a group or team; Includes conflict situations; Requires dealing with unpleasant, angry, or discourteous people; Requires being exact or highly accurate; Mistakes are not easily correctable and have serious consequences; Requires meeting strict deadlines; Requires work with external customers or the public; Includes responsibility for work outcomes and results; Requires working in a office/cubicle environment; Requires lifting/carrying up to 25 lbs. when transporting work equipment or materials

License, Certification or Registration

  • Registered Nurse (RN) with current Texas license
  • Preferred: Coding or utilization review certification


  • 5 years clinical
  • 2 years clinical experience in an inpatient setting
  • 3 years utilization review
  • 2 years supervisory
  • 2 years medical record review
  • Preferred: Medicare review
  • Preferred: Inpatient, outpatient or home health utilization review
  • Preferred: Durable medical equipment (DME) retrospective review
  • Preferred: Determining medical necessity using InterQual and/or local and national coverage determination guidelines


  • Basic knowledge of ICD-9, CPT and HCPCS Coding
  • Current Texas Driver License (Class C) and proof of current Texas minimum auto liability insurance

Skills Required
Basic Skills

  • Active Learning, Active Listening, Communication, Critical Thinking, Learning Strategies, Mathematics, Monitoring, Organization, Reading Comprehension, Science, Speaking, Writing

Social Skills

  • Coordination, Instructing, Negotiation, Persuasion, Service Orientation, Social Perceptiveness

Complex Problem Solving Skills

  • Complex Problem Solving

Technical Skills

  • Operations Analysis, Quality Control Analysis, Troubleshooting

Systems Skills

  • Judgment and Decision Making

Resource Management Skills

  • Time Management, Management of Material Resources, Management of Personnel Resources

Desktop Computer Skills

  • Spreadsheets, Presentation Software, Internet, Navigation, Word Processing, Databases

Knowledge Required
Basic Utilization Management, Law and Government, Mathematics, Clerical, Customer and Personal Service, English Language

TMF offers an excellent benefits package, including:

  • Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
  • Section 125 plan
  • 401K
  • Competitive salary
  • License/credentials reimbursement


TMF Health Quality Institute is an equal opportunity employer.

About this company
TMF Health Quality Institute focuses on promoting quality health care through contracts with federal, state and local governments, as well...