Senior Manager of Provider Escalations

Job Summary

Seeking a detail-oriented Senior Manager of Provider Escalations, this full-time remote position will manage complex provider claims disputes, lead root cause investigations, and collaborate with cross-functional teams to implement solutions and enhance training for vendor and offshore teams.

Key responsibilities

• Serve as the final escalation authority for complex claims disputes and appeals, ensuring accuracy and compliance
• Lead research into CMS guidelines and federal regulations to support pricing and appeal determinations
• Design and implement a Root Cause and Corrective Action (RCCA) program to identify and resolve systemic issues

Required qualifications

• 6-8+ years of experience in healthcare claims processing, payment integrity, or revenue cycle operations
• Deep knowledge of CMS guidelines, MAC coverage policies, and claims processing rules
• Proven ability to research and apply complex Medicare/CMS statutes to resolve disputes
• Experience in designing and executing structured RCCA initiatives with measurable outcomes
• Advanced analytical skills using tools like Excel, SQL, or BI tools to track metrics and trends