Senior Appeals & Denials Resolution Manager

Big Health

. Establish and lead payer appeals and denial resolution operations .

Posted 11/10/2026full-timeRemote • United StatesSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing payer appeals and denial resolution operations, with a strong focus on complex appeal ownership, operational workflow design, and effective communication with cross-functional teams. Proven ability to analyze denial cases, develop appeal strategies, and oversee quality assurance in a fast-paced healthcare environment.

Highest-signal resume keywords

Payer Appeals ManagementComplex Appeal OwnershipHealthcare ReimbursementOperational Workflow DesignAnalytical Problem-Solving

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Denial ManagementCPT/HCPCS CodingAppeal WritingData AnalysisDocumentation ManagementQuality OversightCase Volume ManagementReimbursement MethodologiesPayer CommunicationEscalation Judgment

Soft Skills

LeadershipCommunicationAnalytical SkillsDetail OrientationJudgment

Tools & Technologies

AI-Supported Revenue Cycle SoftwareOperational KPIs TrackingCase Management Systems

Certifications & Qualifications

CPCCPMACRCR

Industry Keywords

Healthcare AdministrationRevenue CycleBehavioral HealthDigital HealthMedical DevicesSpecialty HealthcarePayer PoliciesInvestigational PoliciesExternal ReviewCommercial Payer Processes

About the role

Key responsibilities & impact

Establish and lead payer appeals and denial resolution operations
Manage end-to-end appeals from denial intake through resolution, including prioritization, workload allocation, quality oversight, initial and second-level appeals, reconsiderations, and external reviews when applicable
Personally handle complex medical necessity, investigational/experimental, noncovered service, coding, and reimbursement-related denials
Build case-specific appeal strategies using clinical records, research, payer policies, coding guidance, and applicable appeal requirements
Assess deadlines, documentation needs, appeal merit, escalation options, and case closure decisions
Communicate with payer claims, provider relations, medical policy, utilization management, and clinical review teams
Investigate denial bases and determine evidence, review, or corrective actions that could change outcomes
Distinguish coverage restrictions from administrative errors, coding problems, documentation gaps, and pricing disputes
Document payer contacts, policy citations, findings, commitments, and follow-up actions; escalate systemic policy issues
Build standardized operating procedures for intake, triage, appeal drafting, submission, follow-up, escalation, quality review, and closure
Maintain complete case records and manage operational capacity, workload prioritization, productivity expectations, provider communication standards, and quality controls
Coordinate with providers and cross-functional partners to obtain supporting documentation and resolve exceptions
Own AI-supported appeals workflows and review AI outputs for factual accuracy, evidence quality, completeness, and payer-specific requirements
Retain human responsibility for submissions, complex payer engagement, judgment-intensive exceptions, and quality assurance
Track overturn rates, case aging, cycle times, reimbursement recovered, workload, and recurring root causes
Translate payer findings into recommendations for operational performance and access and reimbursement strategy
Report to Market Access leadership and collaborate with Clinical, Legal, Finance, and provider-facing teams
Serve as operational leader and primary subject-matter expert for appeals and denial resolution, including team readiness, performance standards, training, and oversight of additional resources
Own operational KPIs, identify resource and staffing needs, and recommend improvements for scalability and business objectives

Requirements

What you’ll need

Bachelor’s degree in healthcare administration, business, health sciences, or related discipline, or equivalent professional experience
7+ years of progressive experience in healthcare reimbursement, revenue cycle, denial management, or payer appeals
3+ years of complex-appeal ownership
0–2 years of management experience, with demonstrated experience leading operational workflows, managing performance, or overseeing appeals resources
Demonstrated success overturning challenging commercial payer denials
Working knowledge of commercial payer and Medicare appeal processes, medical policies, CPT/HCPCS coding, remittance advice, denial codes, and reimbursement methodologies
Excellent appeal-writing skills, payer communication and escalation judgment, detailed case documentation, and analytical problem-solving
Experience designing operational workflows, managing substantial case volumes, and meeting payer-specific timelines with limited supervision
Strong analytical skills, including data analysis and resource management
Preferred: experience in behavioral health, digital health, medical devices, specialty healthcare, or emerging technologies
Preferred: familiarity with newer HCPCS codes, FDA-cleared therapies, investigational policies, and independent external review
Preferred: experience transitioning outsourced appeals in-house or implementing AI-supported revenue cycle software
Relevant credentials such as CPC, CPMA, or CRCR preferred
Preferred: experience mentoring or supervising appeals staff

Benefits

Comp & perks

Full-time employment
Remote-first work arrangement
Role can be based anywhere in the United States
Equity and benefits may be included in total compensation (specific benefits not enumerated)