Senior Appeals & Denials Resolution Manager

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🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

👔 Manager

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Big Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2010

💼 Consulting

📣 Marketing

🏥 Healthcare

💰 $75M Series C on 2022-01

Consulting • Marketing • Healthcare

Big Health is a company focused on making effective mental health care accessible through digital solutions. They offer a comprehensive platform with programs such as Sleepio, Daylight, and Spark Direct, which help individuals improve sleep, manage anxiety, and enhance mood, respectively. Big Health serves employers, health plans, and benefits consultants, aiming to overcome barriers to mental health care like stigma, financial difficulties, and access issues. Their mission is to empower people and organizations to take control of their mental health with evidence-based digital programs that are inclusive, scalable, and affordable.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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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