Senior Manager, Payment Integrity, Provider Escalation

🔥 8 minutes ago

🇺🇸 United States – Remote

💵 $110.5k - $150k / year

⏰ Full Time

🟠 Senior

👔 Manager

👻 Ghost score 0%

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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