Senior Manager, Payment Integrity and Provider Escalation

Job Description

A bit about this role:

• The Senior Manager of Payment Integrity is responsible for data-driven research and root-cause analyses related to payment integrity provider disputes and escalations to facilitate resolution and drive education in support of Devoted’s collaborative provider relationships.
• In this role, the Senior Manager directly oversees Payment Integrity disputes and appeals delivery teams. This role will own day-to-day operations and support, including end-to-end queue management, operational timeliness, quality assurance, training, and strict adherence to service level agreements (SLAs).
• The Senior Manager partners closely with leadership and operational support teams to ensure edits, audits, and reviews are executed properly while monitoring compliance with organizational and regulatory standards.

Your Responsibilities and Impact will include:

• Operational & SLA Management: Direct, mentor, and oversee the Payment Integrity (PI) disputes and appeals delivery team, driving daily queue health, turnaround times, quality assurance, and strict SLA compliance across all claim disputes and escalations.
• Dual-Track Subject Matter Expertise: Serve as the definitive Subject Matter Expert (SME) on complex billing guidelines, reimbursement policies, and CMS regulations (e.g., NCCI, LCD/NCDs), acting as the primary point of escalation for delivery teams and internal cross-functional partners on high-complexity claims.
• Root-Cause & Trend Analysis: Perform granular trend analyses on dispute data—evaluating CPT/HCPCS codes, modifiers, billing taxonomy, facilities, and regions—to identify volume spikes, billing errors, and underlying system or policy root causes.
• Upstream Synergy & Policy Optimization: Translate dispute and appeal insights into actionable recommendations for upstream PI edit and audit teams to refine logic, eliminate policy ambiguities, reduce overturn rates, and mitigate future dispute volume over time.
• Leadership Reporting & Escalations: Represent Payment Integrity dispute performance to senior leadership through clear operational reporting and trend updates; step in directly to resolve high-priority provider escalations.
• Audit Readiness & Governance: Maintain rigorous documentation logs, SOPs, and quality control frameworks for claim research to ensure continuous audit readiness for CMS program audits, state regulatory reviews, and internal compliance evaluations.
• External Provider Enablement: Collaborate across clinical, coding, and operational teams to leverage payment integrity dispute findings into targeted external billing guidance, clear policy documentation, and provider education.
• Process Modernization: Identify opportunities to leverage AI tools, automation, and LLM-assisted workflows to accelerate research, improve log quality, and streamline daily operational throughput.

Required skills and experience:

• 5+ Years of Healthcare PI & Dispute Experience: Proven track record in healthcare payment integrity, provider dispute management, coding/clinical documentation review, or claim audit operations.
• 3+ Years of supervisory or people management experience.
• Deep CMS & Coding Expertise: Extensive mastery of CMS regulations governing Medicare Advantage disputes, organization determinations, and auditing protocols, paired with expert-level knowledge of CPT, HCPCS, ICD-10, UB-04, NCCI edits, and NCD/LCD guidelines.
• Balanced SME & Operational Leadership: Demonstrated ability to manage operational metrics, queue throughput, and team performance while simultaneously serving as the high-level SME for complex medical record reviews and coding/clinical determinations.
• Root-Cause Analytics & Data Proficiency: Strong analytical background in synthesizing claims data, research findings, and medical records to identify systematic gaps, establish defensible audit decisions, and drive upstream process fixes.
• Enterprise Collaboration & Communication: Exceptional cross-functional collaboration skills with a track record of aligning processes across enterprise dispute, clinical, audit, and leadership teams, as well as presenting complex performance metrics to executives.

Desired skills and experience :

• Active medical coding certification from AAPC or AHIMA (e.g., CPC, CIC, COC, or RHIA/RHIT)

• Hands-on experience or familiarity with implementing LLMs, AI-driven claim intake tools, or process automation (RPA) to optimize log tracking, research efficiency, and operational speed.
• Familiarity with healthcare data tools (e.g., SQL, Tableau, Power BI) or claim editing engine logic (e.g., Cotiviti, Optum, Change Healthcare)

• Prior experience in Provider Relations or Network Management, with a knack for turning technical payment integrity findings into clear, digestible provider-facing education materials and billing guidance.

• Proven conflict resolution skills when negotiating complex, high-dollar, or executive-level provider escalations.
• AI & Automation Aptitude: Practical experience or strong curiosity and hands-on aptitude for adopting AI tools, automation, and LLM-based workflows to increase team productivity, efficiency, and operational accuracy.

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Salary range: $110,500 - $150,000 /year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium

• Generous paid time off

• $100 monthly mobile or internet stipend

• Stock options for all employees

• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles

• Parental leave program

• 401K program

• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.