Senior Appeals & Denials Resolution Manager

🕒 Ontem

🇺🇸 Estados Unidos – Remoto (EUA)

⏰ Tempo Integral

🟠 Sênior

👔 Gerente

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Big Health

SiteLinkedInTodas as Vagas

51 - 200 funcionários

Fundada em 2010

💼 Consultoria

📣 Marketing

🏥 Saúde

💰 $75.000.000 Series C em 2022-01

Consulting • Marketing • Healthcare

A Big Health é uma empresa focada em tornar o cuidado com a saúde mental acessível através de soluções digitais. Eles oferecem uma plataforma abrangente com programas como Sleepio, Daylight e Spark Direct, que ajudam as pessoas a melhorar o sono, gerenciar a ansiedade e melhorar o humor, respectivamente. A Big Health atende empresas, planos de saúde e consultores de benefícios, visando superar barreiras ao cuidado com a saúde mental, como estigma, dificuldades financeiras e questões de acesso. Sua missão é capacitar pessoas e organizações a tomar o controle de sua saúde mental com programas digitais baseados em evidências, que são inclusivos, escaláveis e acessíveis.

Descrição

• Establish and lead payer appeals and denial resolution operations • Manage end-to-end appeals from denial intake through resolution, including prioritization, workload allocation, quality oversight, initial and second-level appeals, reconsiderations, and external reviews when applicable • Personally handle complex medical necessity, investigational/experimental, noncovered service, coding, and reimbursement-related denials • Build case-specific appeal strategies using clinical records, research, payer policies, coding guidance, and applicable appeal requirements • Assess deadlines, documentation needs, appeal merit, escalation options, and case closure decisions • Communicate with payer claims, provider relations, medical policy, utilization management, and clinical review teams • Investigate denial bases and determine evidence, review, or corrective actions that could change outcomes • Distinguish coverage restrictions from administrative errors, coding problems, documentation gaps, and pricing disputes • Document payer contacts, policy citations, findings, commitments, and follow-up actions; escalate systemic policy issues • Build standardized operating procedures for intake, triage, appeal drafting, submission, follow-up, escalation, quality review, and closure • Maintain complete case records and manage operational capacity, workload prioritization, productivity expectations, provider communication standards, and quality controls • Coordinate with providers and cross-functional partners to obtain supporting documentation and resolve exceptions • Own AI-supported appeals workflows and review AI outputs for factual accuracy, evidence quality, completeness, and payer-specific requirements • Retain human responsibility for submissions, complex payer engagement, judgment-intensive exceptions, and quality assurance • Track overturn rates, case aging, cycle times, reimbursement recovered, workload, and recurring root causes • Translate payer findings into recommendations for operational performance and access and reimbursement strategy • Report to Market Access leadership and collaborate with Clinical, Legal, Finance, and provider-facing teams • Serve as operational leader and primary subject-matter expert for appeals and denial resolution, including team readiness, performance standards, training, and oversight of additional resources • Own operational KPIs, identify resource and staffing needs, and recommend improvements for scalability and business objectives

🎯 Requisitos

• Bachelor’s degree in healthcare administration, business, health sciences, or related discipline, or equivalent professional experience • 7+ years of progressive experience in healthcare reimbursement, revenue cycle, denial management, or payer appeals • 3+ years of complex-appeal ownership • 0–2 years of management experience, with demonstrated experience leading operational workflows, managing performance, or overseeing appeals resources • Demonstrated success overturning challenging commercial payer denials • Working knowledge of commercial payer and Medicare appeal processes, medical policies, CPT/HCPCS coding, remittance advice, denial codes, and reimbursement methodologies • Excellent appeal-writing skills, payer communication and escalation judgment, detailed case documentation, and analytical problem-solving • Experience designing operational workflows, managing substantial case volumes, and meeting payer-specific timelines with limited supervision • Strong analytical skills, 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 • Preferred: experience transitioning outsourced appeals in-house or implementing AI-supported revenue cycle software • Relevant credentials such as CPC, CPMA, or CRCR preferred • Preferred: experience mentoring or supervising appeals staff

🏖️ Benefícios

• Full-time employment • Remote-first work arrangement • Role can be based anywhere in the United States • Equity and benefits may be included in total compensation (specific benefits not enumerated)

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