Senior Manager, Payment Integrity, Provider Escalation

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

📋 Description

• Lead, guide, and supervise the Payment Integrity disputes and appeals delivery team.

• Oversee daily queue management, turnaround times, quality assurance, and compliance with SLAs across claim disputes and escalations.

• Act as the subject matter expert on billing guidelines, reimbursement policies, and CMS regulations.

• Serve as the main escalation point for complex claim issues.

• Conduct detailed trend analyses of dispute data, encompassing CPT/HCPCS codes, modifiers, billing taxonomy, facilities, and geographic regions.

• Detect billing inaccuracies, volume surges, and identify root causes related to systems or policies.

• Convert insights from disputes and appeals into actionable recommendations for upstream payment integrity edit and audit teams.

• Present dispute performance metrics to senior leadership through operational reports and trend analyses.

• Address high-priority provider escalations.

• Keep documentation logs, standard operating procedures, and quality control frameworks ready for audits.

• Work in collaboration with clinical, coding, and operational teams to provide guidance and education on provider billing.

• Discover opportunities to leverage AI tools, automation, and LLM-assisted workflows to enhance research and operational efficiency.

⛳️ Requirements

• 5+ years of experience in healthcare payment integrity, provider dispute management, coding/clinical documentation review, or claim audit operations.

• 3+ years of experience in a supervisory or people management role.

• Comprehensive knowledge of CMS regulations related to Medicare Advantage disputes, organizational determinations, and auditing protocols.

• Expert understanding of CPT, HCPCS, ICD-10, UB-04, NCCI edits, and NCD/LCD guidelines.

• Capability to oversee operational metrics, queue throughput, and team performance while acting as a high-level subject matter expert for complex medical record reviews and coding/clinical assessments.

• Strong analytical skills in integrating claims data, research outcomes, and medical records.

• Excellent cross-functional collaboration and presentation abilities at the executive level.

• Active medical coding certification from AAPC or AHIMA (e.g., CPC, CIC, COC, or RHIA/RHIT) is preferred.

• Practical experience or familiarity with LLMs, AI-driven claim intake tools, or robotic process automation (RPA) is preferred.

• Knowledge of SQL, Tableau, Power BI, or claim editing engine logic such as Cotiviti, Optum, or Change Healthcare is preferred.

• Previous experience in Provider Relations or Network Management is preferred.

• Demonstrated conflict resolution abilities for complex, high-value, or executive-level provider escalations.

• Hands-on experience or a strong interest in AI tools, automation, and LLM-based workflows is preferred.

🏝️ Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.

• Generous paid time off.

• $100 monthly stipend for mobile or internet expenses.

• Stock options available to all employees.

• Eligibility for bonuses for all positions, excluding Director and above.

• Parental leave program.

• 401K program.