Senior Manager, Payment Integrity and Provider Escalation

devoted; United States; On-site; USD 180,000 - 230,000; Full time

Job summary

Devoted is seeking a Senior Manager of Payment Integrity to oversee disputes and appeals delivery teams, directing end-to-end operations and SLA adherence across all claim reviews.

You will partner with leadership, drive data-driven analyses of CPT/HCPCS codes and CMS guidelines, and translate findings into actionable provider education and policy enhancements. This role emphasizes cross-functional collaboration, audit readiness, and innovative use of AI and automation to improve throughput.

Qualifications

• 5+ years in Healthcare PI and dispute management.
• 3+ years of supervisory or people management experience.
• Deep CMS & coding knowledge: CPT, HCPCS, ICD-10, NCCI, NCD/LCD guidelines.
• Strong analytical skills for root-cause analysis of disputes.
• Ability to translate findings into provider-facing guidance.

Responsibilities

• Operational & SLA Management: oversee PI disputes and appeals delivery team and ensure SLA compliance.
• Serve as SME on CMS regulations and billing guidelines.
• Perform trend analyses on dispute data and CPT/HCPCS to identify root causes.
• Translate insights into actionable recommendations to upstream teams.
• Represent performance to senior leadership with clear reporting.
• Maintain documentation and audit readiness for CMS/state audits.
• Collaborate across clinical, coding and operational teams to educate providers.
• Identify opportunities to leverage AI tools to improve throughput.

Skills

Healthcare PI

Leadership

CMS Regulations

Coding Expertise

Data Analytics

Communication

Education

Medical coding certification

Tools

SQL

Tableau

Power BI

Cotiviti

Optum

Change Healthcare

Job description

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 curiosi