Senior Manager, Provider Escalation and Education

🔥 32 minutes ago

🇺🇸 United States – Remote

💵 $110.5k - $150k / year

⏰ Full Time

🟠 Senior

👔 Manager

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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

• Serve as the ultimate escalation authority for highly complex claims disputes, Out-of-Network (OON) pricing appeals, and intricate coding and billing challenges, including MUEs, NCCI edits, unbundling, and multiple procedure reductions • Own end-to-end resolution of high-priority Complaints Tracking Module (CTM) cases, appeals, and complex provider disputes • Research evolving CMS guidelines, MAC coverage policies, LCDs/NCDs, and federal regulations to support and defend pricing and appeal determinations • Partner with technical teams to build automation, custom logic rules, and AI-enabled workflows for appeals and escalations • Ensure CTM investigations and provider dispute resolutions meet regulatory compliance standards and SLA benchmarks • Design and run a Root Cause and Corrective Action (RCCA) program • Partner with Claims Engineering, Configuration, and Payment Integrity teams to implement system-level fixes • Establish reporting rhythms and escalation protocols for leadership visibility into trends, risks, and regulatory friction points • Serve as the primary educational authority for vendor and offshore teams by developing training, SOPs, and job aids • Report to the Director / Head of Provider Escalations & Education

🎯 Requirements

• 6–8+ years of hands-on experience in healthcare claims processing, payment integrity, coding appeals, or revenue cycle operations • Deep operational mastery of CMS guidelines, MAC coverage policies, NCCI edits, MUEs, multiple procedure reduction rules, and fee schedule logic • Proven track record of independently researching, interpreting, and applying complex Medicare/CMS statutes and billing policies to resolve high-stakes disputes • Demonstrated experience designing and executing structured Root Cause and Corrective Action (RCCA) initiatives that deliver measurable results • Exceptional attention to detail, with a reputation for getting complex claims determinations exactly right • Excellent written and verbal communication skills, with the ability to distill technical regulatory and claims information into clear narratives for executive decision-making • Advanced analytical skills using Excel/Google Sheets, SQL, or BI tools (e.g., Tableau, Looker) to track CTM and appeals metrics and identify operational trends • Experience training or guiding distributed teams and external vendors • Certified Professional Coder (CPC) credential • Experience deploying automation or AI-enabled workflows in a claims or appeals environment

🏖️ 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 • Commission eligibility for Sales roles • Parental leave program • 401K program

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