Executive Escalations Specialist

Sr Executive Escalations Specialist

ATI is looking for a Sr Executive Escalations Specialist for our remote client. The Sr. Executive Escalations Specialist reports to the Manager, Executive Escalations and serves as a senior individual contributor responsible for the end-to-end resolution of our most complex, sensitive, and high-risk medical and dental escalations. This role functions as an expert-level investigator and trusted escalation owner, handling cases that carry heightened regulatory, reputational, financial, and/or executive visibility, including OPM grievances and leadership-referred matters. The Sr. Executive Escalations Specialist operates with substantial independence, applying advanced judgment, investigative rigor, and executive-level communication skills while representing us with professionalism and discretion. This position is a part of the broader Product Intelligence & Strategy team. In addition to supporting the Manager, Executive Escalations in strengthening escalation practices, quality standards, and risk mitigation efforts, this role contributes to organizational insights and continuous improvement by identifying systemic issues, surfacing trends, and influencing strategic decisions.

Duties and Responsibilities

• Executive Escalation Management
• Own the end-to-end management of the organization's most complex medical and dental escalations, including high-profile member complaints, leadership escalations, and OPM grievances.
• Represent professionally and accurately in communications with members, providers, senior leaders, regulators, and external stakeholders.
• Manage cases with heightened sensitivity to reputational risk, compliance obligations, and public perception, escalating appropriately to leadership when risk thresholds are met.
• Ensure timely, accurate, and defensible resolution outcomes that balance member advocacy, plan integrity, and regulatory requirements.
• Advanced Investigation & Root Cause Analysis
• Ensure that comprehensive investigative reviews are conducted across claims adjudication, eligibility, benefit interpretation, call recordings, written correspondence, and process workflows.
• Perform detailed examinations of complex medical and dental claims to identify processing errors, policy misapplication, or systemic breakdowns.
• Apply structured root cause analysis techniques to differentiate between individual defects and broader process or system issues.
• Develop clear, well-supported findings and resolution rationales suitable for executive review or regulatory response.
• Cross-Functional Collaboration
• Partner closely with operations, customer service, clinical teams, compliance, legal, and vendors to drive resolution of complex escalations.
• Participate in cross-functional working sessions to resolve cases and address systemic issues surfaced through executive escalations.
• Serve as a subject matter resource for complex or precedent-setting escalation scenarios.
• Executive-Level Communication & Reporting
• Draft high-quality written responses and summaries on behalf of the Executive Escalations function, ensuring clarity, professionalism, and accuracy.
• Provide concise case summaries, insights, and escalation updates to the Manager, Executive Escalations and other leadership stakeholders.
• Support escalation tracking, documentation, and reporting efforts to ensure transparency, accountability, and audit readiness.
• Intelligence & Continuous Improvement
• Identify recurring trends, risks, and breakdown points across escalations handled.
• Provide input and recommendations to leadership on process improvements affecting claims accuracy, member experience, and escalation prevention.
• Support quality initiatives and evolving investigative standards established by the Manager, Executive Escalations.

Education & Experience Requirements

• Bachelor's degree in a related field required; equivalent experience may be considered in lieu of formal education.
• Minimum of 7 years experience in a medical and/or dental health plan environment.
• Advanced experience in complex claims adjudication, including deep understanding of medical and/or dental benefits, policies, and regulatory considerations.
• Demonstrated experience handling high-risk, high-visibility member escalations requiring strong judgment and discretion.
• Experience working escalations involving executive leadership or regulatory entities strongly preferred.

Required Skills & Competencies

• Advanced analytical, investigative, and critical-thinking capabilities.
• Strong independent judgment and ability to manage ambiguity in high-pressure situations.
• Exceptional written and verbal communication skills, including executive-level correspondence.
• Demonstrated knowledge in Lean and process improvement methodologies.
• Deep understanding of claims adjudication processes, medical terminology, and benefit interpretation.
• High degree of professionalism, discretion, and accountability.
• Ability to summarize findings and insights using Excel, PowerPoint, and/or BI tools.

Preferred Qualifications

• Experience with the Federal Employees Health Benefits Program (FEHB) and/or Federal Employees Dental and Vision Insurance Program (FEDVIP).
• Prior exposure to grievances, appeals, compliance inquiries, or regulatory response processes.
• Experience supporting quality improvement or risk mitigation initiatives within escalation or claims environments.

Work-at-Home Requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30 mbps download x 5 mbps upload) is required.
• Latency (ping) response time lower than 80 ms.
• Hotspots, satellite, and wireless internet services are NOT allowed for this role.
• A dedicated space lacking ongoing interruptions is required to protect member PHI / HIPAA information.