Senior Appeals & Denials Resolution Manager

Big Health

1d•$120,000 - $140,000•Remote

About The Position

Big Health is seeking an experienced, results-driven Senior Appeals & Denials Resolution Manager to establish and lead payer appeals and denial resolution operations. The role independently investigates difficult denials, develops evidence-based appeals, engages payer reviewers and decision-makers, and manages cases through appropriate levels of review. The manager also designs scalable workflows, documentation standards, reporting, and quality controls, using AI-enabled technology to improve efficiency while maintaining human oversight. Big Health is a remote-first company, and this role can be based anywhere in the United States. The position serves as the operational leader and primary subject-matter expert for appeals and denial resolution, with accountability for performance, team readiness, training, quality, and scaling the function.

Requirements

Bachelor’s degree in healthcare administration, business, health sciences, or a related discipline, or equivalent professional experience.
7 or more years of progressive experience in healthcare reimbursement, revenue cycle, denial management, or payer appeals.
3 or more 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, with the ability to explain investigative methods and results.
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.

Nice To Haves

Experience in behavioral health, digital health, medical devices, specialty healthcare, or emerging technologies.
Familiarity with appeals involving newer HCPCS codes, FDA-cleared therapies, investigational policies, and independent external review.
Experience transitioning outsourced appeals in-house or implementing AI-supported revenue cycle software.
Relevant credentials such as CPC, CPMA, or CRCR.
Experience mentoring or supervising appeals staff.

Responsibilities

Manage end-to-end appeals operations from denial intake through resolution, including prioritization, workload allocation, quality oversight, and timely completion of initial and second-level appeals, reconsiderations, and external reviews when applicable.
Personally handle complex medical necessity, investigational or experimental, noncovered service, coding, and reimbursement-related denials.
Develop case-specific appeal strategies supported by clinical records, research, payer policies, coding guidance, and applicable appeal requirements.
Assess deadlines, documentation needs, appeal merit, escalation options, and case closure decisions, and ensure timely and accurate submissions.
Communicate directly with payer claims, provider relations, medical policy, utilization management, and clinical review teams as appropriate.
Investigate the basis for denials or upheld decisions and identify evidence, review, or corrective action that may change the outcome.
Distinguish benefit exclusions and coverage-policy restrictions from administrative errors, coding problems, documentation gaps, and pricing disputes.
Document payer contacts, reference numbers, policy citations, findings, commitments, and follow-up actions; escalate systemic policy issues to Market Access leadership.
Build standardized operating procedures for intake, triage, appeal drafting, submission, follow-up, escalation, quality review, and closure.
Maintain complete case records covering denial rationale, appeal history, evidence, correspondence, deadlines, and final disposition.
Manage operational capacity, workload prioritization, productivity expectations, provider communication standards, and quality controls to ensure timely resolution and prevent missed appeal deadlines.
Coordinate with providers and cross-functional partners to obtain complete supporting documentation and resolve exceptions.
Own AI-supported appeals workflows, including draft generation, document review, tracking, and routine payer follow-up.
Review AI-produced 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.
Identify workflow improvements while adhering to privacy, security, and compliance requirements.
Track appeal overturn rates by payer, denial reason, and level; case aging; cycle times; reimbursement recovered; workload; and recurring root causes.
Translate payer findings into recommendations that improve operational performance and inform access and reimbursement strategy.
Provide regular reporting to Market Access leadership and work closely with Clinical, Legal, Finance, and provider-facing teams.
Lead appeals and denial resolution operations, including team readiness, performance standards, training, and oversight of additional resources as the function scales.
Own operational performance against defined KPIs, identify resource and staffing needs, and recommend improvements to support scalability and business objectives.