Senior Appeals & Denials Resolution Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Establish and oversee the operations for payer appeals and denial resolution.

• Manage the complete appeal process from denial intake to resolution, including prioritization, workload distribution, quality oversight, initial and secondary appeals, reconsiderations, and external reviews when necessary.

• Personally address complex denials related to medical necessity, investigational or experimental services, non-covered services, coding issues, and reimbursement challenges.

• Develop case-specific appeal strategies utilizing clinical documentation, research, payer policies, coding guidelines, and relevant appeal requirements.

• Evaluate deadlines, documentation requirements, appeal validity, escalation possibilities, and decisions for case closure.

• Communicate effectively with payer claims, provider relations, medical policy, utilization management, and clinical review teams.

• Investigate the basis of denials and identify evidence, review processes, or corrective actions that could alter outcomes.

• Differentiate between coverage limitations and administrative errors, coding issues, documentation deficiencies, and pricing disputes.

• Record payer interactions, policy references, findings, commitments, and follow-up actions; escalate systemic policy matters.

• Develop standardized operating procedures for intake, triage, appeal drafting, submission, follow-up, escalation, quality review, and closure.

• Maintain comprehensive case records and manage operational capacity, workload prioritization, productivity expectations, provider communication standards, and quality controls.

• Collaborate with providers and cross-functional teams to gather supporting documentation and resolve exceptions.

• Oversee AI-supported appeal workflows and review AI-generated outputs for factual accuracy, evidence quality, completeness, and compliance with payer-specific requirements.

• Retain ultimate responsibility for submissions, engage with complex payers, manage judgment-intensive exceptions, and ensure quality assurance.

• Monitor overturn rates, case aging, cycle times, recovery amounts, workload, and recurring root causes.

• Translate payer findings into actionable recommendations for enhancing operational performance and reimbursement strategies.

• Report to Market Access leadership and work closely with Clinical, Legal, Finance, and provider-facing teams.

• Act as the operational leader and primary subject-matter expert for appeals and denial resolution, including team readiness, performance standards, training, and management of additional resources.

• Own operational KPIs, identify resource and staffing needs, and suggest improvements for scalability and alignment with business objectives.

⛳️ Requirements

• Bachelor’s degree in healthcare administration, business, health sciences, or a related field, or equivalent professional experience.

• Over 7 years of progressive experience in healthcare reimbursement, revenue cycle management, denial management, or payer appeals.

• At least 3 years of experience in managing complex appeals.

• 0 to 2 years of management experience, demonstrating the ability to lead operational workflows, manage performance, or supervise appeals resources.

• Proven success in overturning difficult commercial payer denials.

• Solid understanding of commercial payer and Medicare appeal processes, medical policies, CPT/HCPCS coding, remittance advice, denial codes, and reimbursement methodologies.

• Excellent skills in appeal writing, payer communication and escalation judgment, detailed case documentation, and analytical problem-solving.

• Experience in designing operational workflows, managing significant case volumes, and adhering to payer-specific timelines with minimal supervision.

• Strong analytical capabilities, including data analysis and resource management.

• Preferred: experience in behavioral health, digital health, medical devices, specialty healthcare, or emerging technologies.

• Preferred: familiarity with newer HCPCS codes, FDA-cleared therapies, investigational policies, and independent external review processes.

• Preferred: experience transitioning outsourced appeals back in-house or implementing AI-enhanced revenue cycle software.

• Relevant credentials such as CPC, CPMA, or CRCR are preferred.

• Preferred: experience in mentoring or supervising appeals staff.

🏝️ Benefits

• Full-time employment.

• Remote-first work environment.

• The role can be based from anywhere in the United States.

• Equity and benefits may be included in the overall compensation package (specific benefits not listed).