Senior Manager, Payment Integrity and Provider Escalation

Devoted Health•Waltham, MA

22h•$110,500 - $150,000•Remote

About The Position

The Senior Manager of Payment Integrity leads data-driven research and root-cause analyses related to payment integrity provider disputes and escalations, supporting resolution and education while fostering collaborative provider relationships. The role directly oversees Payment Integrity disputes and appeals delivery teams and owns day-to-day operations, including end-to-end queue management, operational timeliness, quality assurance, training, and adherence to service level agreements (SLAs). The Senior Manager partners with leadership and operational support teams to ensure edits, audits, and reviews are executed properly and comply with organizational and regulatory standards. The position combines operational leadership with subject matter expertise in complex billing guidelines, reimbursement policies, CMS regulations, and high-complexity claims. It analyzes dispute trends and claim data to identify billing errors and underlying system or policy causes, then recommends improvements to upstream edits and audits. The role also represents dispute performance to senior leadership, resolves high-priority provider escalations, maintains audit-ready documentation and quality frameworks, contributes to provider education, and identifies opportunities to use AI, automation, and LLM-assisted workflows. The position is remote. The listed annual salary range is $110,500–$150,000. Devoted Health describes a total rewards package that includes employer-sponsored health, dental, and vision plans with low or no premium, generous paid time off, a monthly mobile or internet stipend, stock options, bonus eligibility for roles below Director, parental leave, and a 401(k) program. The total rewards package applies to full-time employees only.

Requirements

At least 5 years of experience in healthcare payment integrity, provider dispute management, coding or clinical documentation review, or claim audit operations.
At least 3 years of supervisory or people management experience.
Extensive knowledge of CMS regulations governing Medicare Advantage disputes, organization determinations, and auditing protocols.
Expert-level knowledge of CPT, HCPCS, ICD-10, UB-04, NCCI edits, and NCD/LCD guidelines.
Ability to manage operational metrics, queue throughput, and team performance while serving as the subject matter expert for complex medical record reviews and coding or clinical determinations.
Strong analytical skills in synthesizing claims data, research findings, and medical records to identify systematic gaps, support defensible audit decisions, and drive process improvements.
Exceptional cross-functional collaboration and communication skills, including experience aligning processes across enterprise dispute, clinical, audit, and leadership teams and presenting complex performance metrics to executives.

Nice To Haves

Active medical coding certification from AAPC or AHIMA, such as CPC, CIC, COC, RHIA, or RHIT.
Hands-on experience or familiarity with implementing LLMs, AI-driven claim intake tools, or robotic process automation to improve log tracking, research efficiency, and operational speed.
Familiarity with healthcare data tools such as SQL, Tableau, or Power BI, or claim editing engine logic such as Cotiviti, Optum, or Change Healthcare.
Prior experience in Provider Relations or Network Management and ability to turn technical payment integrity findings into clear provider-facing education and billing guidance.
Proven conflict resolution skills when negotiating complex, high-dollar, or executive-level provider escalations.
Practical experience, or strong curiosity and hands-on aptitude, in adopting AI tools, automation, and LLM-based workflows to improve team productivity, efficiency, and accuracy.

Responsibilities

Direct, mentor, and oversee the Payment Integrity disputes and appeals delivery team, managing daily queue health, turnaround times, quality assurance, and SLA compliance.
Serve as the subject matter expert on complex billing guidelines, reimbursement policies, CMS regulations, and high-complexity claims; act as a primary escalation point for delivery teams and internal partners.
Analyze dispute trends, including CPT/HCPCS codes, modifiers, billing taxonomy, facilities, and regions, to identify volume spikes, billing errors, and system or policy root causes.
Translate dispute and appeal insights into recommendations for upstream Payment Integrity edits and audit teams to refine logic, resolve policy ambiguities, reduce overturn rates, and mitigate future disputes.
Report dispute performance and trends to senior leadership and directly resolve high-priority provider escalations.
Maintain documentation logs, SOPs, and quality control frameworks for claim research to support audit readiness for CMS program audits, state regulatory reviews, and internal compliance evaluations.
Collaborate with clinical, coding, and operational teams to develop external billing guidance, clear policy documentation, and provider education based on dispute findings.
Identify opportunities to use AI tools, automation, and LLM-assisted workflows to accelerate research, improve log quality, and streamline operational throughput.