Accountabilities

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.

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.

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.

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.

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.

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.

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.

Requirements

Bachelor's degree in Healthcare Administration, Business, Health Sciences, or a related discipline, or equivalent professional experience.

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.

Approximately 0–2 years of management experience, with demonstrated capabilities in operational leadership, workflow management, performance oversight, or supervising appeals resources.

Proven success overturning challenging commercial payer denials, with the ability to explain investigative approaches, appeal strategies, and measurable results.

Strong working knowledge of commercial payer and Medicare appeals processes, medical policies, CPT/HCPCS coding, remittance advice, denial codes, and reimbursement methodologies.

Excellent appeal-writing, payer communication, negotiation, escalation, and case documentation skills.

Experience designing operational workflows, managing significant case volumes, meeting strict payer-specific deadlines, and working independently with limited supervision.

Strong analytical and problem-solving abilities, including performance reporting, data interpretation, workload prioritization, and resource management.

Excellent organizational skills, attention to detail, sound judgment, and the ability to collaborate effectively across multidisciplinary teams.

Preferred Qualifications:

Experience in behavioral health, digital health, medical devices, specialty healthcare, or emerging healthcare technologies.

Familiarity with appeals involving newer HCPCS codes, FDA-cleared therapies, investigational policies, and independent external reviews.

How Jobgether works

We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

Why Apply Through Jobgether?

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