Provider Escalation and Education Senior Manager

Accountabilities: Serve as the primary escalation authority for highly complex healthcare claims disputes, out-of-network (OON) pricing appeals, and sophisticated coding and billing challenges, including Medically Unlikely Edits (MUEs), National Correct Coding Initiative (NCCI) edits, unbundling, and multiple procedure reductions. Manage the end-to-end resolution of high-priority Complaints Tracking Module (CTM) cases, appeals, and complex provider disputes, ensuring accuracy, timely resolution, payment integrity, and regulatory compliance. Conduct in-depth research into evolving Centers for Medicare & Medicaid Services (CMS) guidelines, Medicare Administrative Contractor (MAC) coverage policies, Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), and applicable federal regulations to support and justify claims and appeal decisions. Partner with technical and operational teams to develop automation, customized logic rules, and AI-enabled workflows that improve claims intake, escalation routing, and preliminary appeal drafting. Ensure all CTM investigations and provider dispute resolutions comply with applicable regulatory requirements and established service-level agreements (SLAs). Design, implement, and oversee a structured Root Cause and Corrective Action (RCCA) program to identify systemic vulnerabilities, configuration errors, recurring claims issues, and operational bottlenecks. Collaborate with Claims Engineering, Configuration, and Payment Integrity teams to implement sustainable system-level solutions that prevent recurring issues and reduce provider friction. Establish reporting processes, escalation protocols, and performance monitoring practices that provide executive and cross-functional leadership with visibility into claims trends, emerging risks, and regulatory concerns. Translate complex regulatory updates and claims requirements into practical training programs, standard operating procedures (SOPs), and job aids for vendor and offshore teams. Act as a subject matter expert and educational resource, ensuring distributed teams have the knowledge, tools, and guidance needed to resolve claims accurately and consistently. Requirements At least 6–8 years of hands-on professional experience in healthcare claims processing, payment integrity, coding appeals, revenue cycle management, or a closely related field. Extensive operational knowledge of CMS guidelines, Medicare Administrative Contractor (MAC) coverage policies, NCCI edits, MUEs, multiple procedure reduction rules, and Medicare fee schedule logic. Demonstrated ability to independently research, interpret, and apply complex Medicare and CMS regulations, statutes, and billing policies to resolve high-impact claims disputes. Proven experience designing and implementing structured Root Cause and Corrective Action (RCCA) initiatives, with measurable improvements in operational performance and issue prevention. Exceptional attention to detail and a strong track record of delivering accurate, consistent, and well-supported claims determinations. Strong analytical and investigative capabilities, with the ability to identify patterns, uncover systemic issues, and develop practical corrective solutions. Advanced proficiency in Excel or Google Sheets, with experience using SQL and business intelligence tools such as Tableau or Looker to monitor CTM and appeals metrics, analyze trends, and support operational decisions. Excellent written and verbal communication skills, including the ability to translate complex regulatory, technical, and claims-related information into clear recommendations and executive-level reports. Experience training, mentoring, or guiding distributed teams and external vendors, with the ability to develop scalable educational resources and operational procedures. Strong cross-functional collaboration skills, with the ability to work effectively alongside technical, operational, and leadership stakeholders. Ability to manage competing priorities, take ownership of complex investigations, and deliver reliable outcomes in a fast-moving environment. Preferred qualifications: Certified Professional Coder (CPC) credential. Additional advantage: Experience implementing automation solutions or AI-enabled workflows within healthcare claims processing, payment integrity, or appeals operations. Benefits Competitive annual salary: $110,500–$150,000, depending on qualifications, relevant experience, certifications, skills, and work location. Employer-sponsored health, dental, and vision insurance plans with low or no employee premiums. Generous paid time off. Monthly $100 mobile phone or internet stipend. Stock options available to all employees. Bonus eligibility for applicable positions. Comprehensive parental leave program. 401(k) retirement savings program. Additional employee rewards and well-being benefits. Fully remote work opportunity within the United States. Opportunity to contribute to meaningful improvements in healthcare claims operations and the experience of older adults. Collaborative and supportive working environment that values diversity, professional expertise, and continuous improvement.