Senior Manager, Payment Integrity, Provider Escalation

🕒 Outubro 16

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $110.500 - $150.000 / ano

⏰ Tempo Integral

🟠 Sênior

👔 Gerente

👻 Score fantasma 1%

O que significa: a chance de ninguém estar realmente contratando para esta vaga.Como ler: 60% ou mais significa que achamos que é uma vaga fantasma. Pontuações mais baixas preocupam menos.Por que essa pontuação:

• Aberta há 26 dias.
• As vagas desta empresa costumam ser preenchidas em 23 dias.

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Devoted Health

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 2017

🏥 Saúde

⚕️ Seguro de Saúde

🧘 Bem-estar

Healthcare • Healthcare Insurance • Wellness

A Devoted Health é uma empresa de saúde que oferece planos Medicare Advantage projetados para fornecer cobertura de saúde abrangente com benefícios adicionais como cuidados dentários, óculos, associações a academias e medicamentos prescritos a preços competitivos. A empresa enfatiza o suporte e serviço ao membro, garantindo que os clientes possam navegar facilmente por seus benefícios e acessar os serviços de saúde necessários. A Devoted Health está comprometida em ajudar os clientes a economizar dinheiro e melhorar sua saúde e bem-estar por meio de um pacote completo de benefícios e suporte.

Descrição

• Direct, mentor, and oversee the Payment Integrity disputes and appeals delivery team • Manage daily queue health, turnaround times, quality assurance, and SLA compliance across claim disputes and escalations • Serve as the subject matter expert on billing guidelines, reimbursement policies, and CMS regulations • Act as the primary escalation point for high-complexity claims • Perform granular trend analyses of dispute data, including CPT/HCPCS codes, modifiers, billing taxonomy, facilities, and regions • Identify billing errors, volume spikes, and system or policy root causes • Translate dispute and appeal insights into recommendations for upstream payment integrity edit and audit teams • Represent dispute performance to senior leadership through operational reporting and trend updates • Resolve high-priority provider escalations • Maintain documentation logs, SOPs, and quality control frameworks for audit readiness • Collaborate with clinical, coding, and operational teams on provider billing guidance and education • Identify opportunities to use AI tools, automation, and LLM-assisted workflows to improve research and operational throughput

🎯 Requisitos

• 5+ years of healthcare payment integrity, provider dispute management, coding/clinical documentation review, or claim audit operations experience • 3+ years of supervisory or people management experience • Extensive mastery of CMS regulations governing Medicare Advantage disputes, organization determinations, and auditing protocols • Expert-level knowledge of CPT, HCPCS, ICD-10, UB-04, NCCI edits, and NCD/LCD guidelines • Ability to manage operational metrics, queue throughput, and team performance while serving as a high-level SME for complex medical record reviews and coding/clinical determinations • Strong analytical background in synthesizing claims data, research findings, and medical records • Exceptional cross-functional collaboration and executive presentation skills • Active medical coding certification from AAPC or AHIMA (e.g., CPC, CIC, COC, or RHIA/RHIT) desired • Hands-on experience or familiarity with LLMs, AI-driven claim intake tools, or RPA desired • Familiarity with SQL, Tableau, Power BI, or claim editing engine logic such as Cotiviti, Optum, or Change Healthcare desired • Prior Provider Relations or Network Management experience desired • Proven conflict resolution skills for complex, high-dollar, or executive-level provider escalations • Practical experience or strong curiosity and hands-on aptitude with AI tools, automation, and LLM-based workflows desired

🏖️ Benefícios

• Employer sponsored health, dental and vision plan with low or no premium • Generous paid time off • $100 monthly mobile or internet stipend • Stock options for all employees • Bonus eligibility for all roles excluding Director and above • Parental leave program • 401K program

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