Provider Escalation and Education Senior Manager

Devoted Health; United States; Remote; USD 111,000 - 150,000; Full time

Benefits offered by this job

Health, dental & vision plan

Generous paid time off

$100 monthly mobile or internet

Stock options

Bonus eligibility

Parental leave program

401K program

Job summary

Devoted Health is seeking a Senior Manager to lead Provider Escalations & Education, resolving complex claims disputes with deep Medicare knowledge and rigorous regulatory research. The role drives scalable processes, RCCA programs, and cross-functional collaboration with Claims Engineering, Configuration, and Payment Integrity teams.

The ideal candidate combines regulatory mastery with hands-on leadership, excels at interpreting CMS policy, and thrives in a fast-moving environment shaping how

Qualifications

• 6–8+ years in healthcare claims, payment integrity, or revenue cycle ops.
• Mastery of CMS guidelines, MAC policies, NCCI edits, MUEs, and fee schedule logic.
• Ability to research and apply Medicare/CMS statutes to resolve high-stakes disputes.
• Experience designing RCCA programs with measurable results.
• Attention to detail with accuracy in complex claims determinations.
• Strong written and verbal communication for executive decision-making.
• Advanced analytics using Excel/Sheets, SQL, or BI tools to track metrics.
• Experience training distributed teams and external vendors.

Responsibilities

• Serve as the ultimate escalation authority for highly complex claims disputes and pricing.
• Own end-to-end resolution of CTM cases with accountability for accuracy and timeliness.
• Lead research into CMS guidelines to support pricing and appeals determinations.
• Partner with technical teams to build automation and AI-enabled workflows.
• Ensure regulatory compliance standards and SLA benchmarks for investigations.
• Design RCCA program to identify vulnerabilities and bottlenecks.
• Collaborate with Claims Engineering, Configuration, and Payment Integrity on fixes.
• Establish reporting rhythms and escalation protocols for leadership visibility.
• Serve as primary educational authority for vendor and offshore teams, creating training and SOPs.

Skills

Healthcare claims

CMS guidelines

NCCI edits

MUEs

Root Cause Analysis

Data analysis

Regulatory research

Communication

Training teams

Education

CPC credential

Tools

Excel/Google Sheets

SQL

Tableau/Looker

Job description

Job Description

A bit about this role:

Devoted Health is seeking a deep claims expert and hands-on leader to serve as Senior Manager, Provider Escalations & Education. This role is designed for a subject matter expert who can resolve our most complex provider claims disputes with precision, defend our determinations with rigorous regulatory research, and turn what we learn from every escalation into fixes that prevent the next one.

Reporting to the [Director / Head] of Provider Escalations & Education, you will serve as the final escalation point for high-complexity claims issues, lead root cause investigations into systemic problems, and partner with Claims, Configuration, Payment Integrity, and Engineering teams to implement durable solutions. You will also equip leadership with clear, concise briefings on trends, risks, and regulatory exposure, and ensure our vendor and offshore teams have the training and tools to get it right the first time.

The best candidate will combine deep mastery of Medicare claims and coding rules, investigative curiosity, obsession with detail, and the ability to translate complex regulatory requirements into clear decisions and scalable processes. This role is ideal for someone who runs to the hardest claims problems, isn't satisfied until the root cause is fixed, and thrives in a fast-moving environment where their expertise directly shapes how we operate.

Your Responsibilities and Impact will include

• Serving as the ultimate escalation authority for highly complex claims disputes, Out-of-Network (OON) pricing appeals, and intricate coding and billing challenges, including MUEs, NCCI edits, unbundling, and multiple procedure reductions
• Owning end-to-end resolution of high-priority Complaints Tracking Module (CTM) cases, appeals, and complex provider disputes, with clear accountability for accuracy, timeliness, and payment integrity
• Leading rigorous research into evolving CMS guidelines, MAC coverage policies, LCDs/NCDs, and federal regulations to support and defend pricing and appeal determinations
• Partnering with technical teams to build automation, custom logic rules, and AI-enabled workflows that streamline intake, routing, and preliminary drafting for appeals and escalations
• Ensuring every CTM investigation and provider dispute resolution meets regulatory compliance standards and SLA benchmarks
• Designing and running a Root Cause and Corrective Action (RCCA) program that identifies systemic vulnerabilities, configuration errors, and claims processing bottlenecks
• Partnering with Claims Engineering, Configuration, and Payment Integrity teams to implement system-level fixes that eliminate recurring provider friction before it reaches regulatory visibility
• Establishing reporting rhythms and escalation protocols that give executive and cross-functional leadership clear visibility into trends, emerging risks, and regulatory friction points
• Serving as the primary educational authority for vendor and offshore teams, converting complex regulatory changes into scalable training, SOPs, and job aids

Required skills and experience

• 6–8+ years of hands-on experience in healthcare claims processing, payment integrity, coding appeals, or revenue cycle operations
• Deep operational mastery of CMS guidelines, MAC coverage policies, NCCI edits, MUEs, multiple procedure reduction rules, and fee schedule logic
• Proven track record of independently researching, interpreting, and applying complex Medicare/CMS statutes and billing policies to resolve high-stakes disputes
• Demonstrated experience designing and executing structured Root Cause and Corrective Action (RCCA) initiatives that deliver measurable results
• Exceptional attention to detail, with a reputation for getting complex claims determinations exactly right
• Excellent written and verbal communication skills, with the ability to distill technical regulatory and claims information into clear narratives for executive decision-making
• Advanced analytical skills using Excel/Google Sheets, SQL, or BI tools (e.g., Tableau, Looker) to track CTM and appeals metrics and identify operational trends
• Experience training or guiding distributed teams and external vendors

Desired skills and experience:

• Certified Professional Coder (CPC) credential
• Experience deploying automation or AI-enabled workflows in a claims or appeals environment

#LI-Remote

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.