Senior Appeals & Denials Resolution Manager
Key details
- Location
- United States
- Work style
- Remote
- Level
- Lead / Staff+
- Job type
- Full-time
- Experience
- 7–10 yrs
- Function
- Customer success & Support
- Focus area
- other
- Posted
- Yesterday
Skills
About the role
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Senior Appeals & Denials Resolution Manager based in the United States.
As a Senior Appeals & Denials Resolution Manager, you will lead the development and execution of comprehensive payer appeals and denial resolution operations within an innovative healthcare environment. You will take ownership of complex reimbursement challenges, investigating difficult claims and developing compelling, evidence-based appeals to improve reimbursement outcomes. Working independently, you will engage directly with payer representatives, clinical reviewers, and decision-makers to resolve challenging cases. You will also establish scalable processes, quality standards, and performance metrics to strengthen operational efficiency. Leveraging AI-enabled technologies alongside human expertise, you will optimize workflows while maintaining accuracy, compliance, and accountability. This is an opportunity to play a strategic role in improving healthcare access and supporting the growth of digital health solutions.
Accountabilities
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Appeals Management & Denial Resolution: Lead end-to-end appeals operations, from initial denial intake and case prioritization to appeal submissions, reconsiderations, second-level reviews, and external reviews when applicable. Personally manage complex medical necessity, investigational, noncovered service, coding, and reimbursement-related denials.
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Appeal Strategy & Execution: Develop persuasive, case-specific appeals supported by clinical documentation, medical research, payer policies, coding guidelines, and applicable regulatory requirements. Evaluate appeal deadlines, supporting evidence, escalation opportunities, and resolution strategies.
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Payer Investigation & Escalation: Communicate directly with payer claims departments, provider relations teams, medical policy specialists, utilization management, and clinical reviewers to investigate denial decisions and identify opportunities for reconsideration. Distinguish coverage restrictions from administrative errors, coding issues, documentation gaps, and pricing disputes.
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Operational Development: Establish standardized procedures for case intake, triage, appeal drafting, submission, follow-up, escalation, quality assurance, and closure. Maintain comprehensive case documentation and ensure compliance with payer-specific timelines and requirements.
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AI-Enabled Operations: Oversee AI-supported appeals workflows, including document review, appeal drafting, case tracking, and routine payer follow-ups. Validate AI-generated outputs for accuracy, completeness, and quality while retaining human oversight of complex decisions and final submissions.
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Performance Monitoring & Reporting: Track key performance indicators, including appeal overturn rates, reimbursement recovered, case aging, resolution timelines, workload, and recurring denial patterns. Translate findings into actionable recommendations to improve reimbursement performance and operational effectiveness.
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Cross-Functional Collaboration & Leadership: Partner with Clinical, Legal, Finance, Market Access, and provider-facing teams to resolve complex cases and improve access strategies. Lead operational readiness, establish performance standards, support training, oversee additional resources as the function grows, and recommend staffing and process improvements.
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Bachelor's degree in Healthcare Administration, Business, Health Sciences, or a related discipline, or equivalent professional experience.
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At least 7 years of progressive experience in healthcare reimbursement, revenue cycle management, denial management, or payer appeals, including at least 3 years of direct ownership of complex appeals.
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Approximately 0–2 years of management experience, with demonstrated capabilities in operational leadership, workflow management, performance oversight, or supervising appeals resources.
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Proven success overturning challenging commercial payer denials, with the ability to explain investigative approaches,
Requirements
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