Senior Manager, Provider Appeals and Dispute Resolution Management

L.A. Care Health Plan•Los Angeles, CA

3d•$135,136 - $216,218•Onsite

About The Position

The Senior Manager of Provider Appeals and Dispute Resolution Management is a key leader responsible for overseeing the full lifecycle of provider appeals, payment disputes, claim escalations, and complex reimbursement issues. This role ensures operational consistency and regulatory compliance by establishing standardized processes for dispute intake, investigation, resolution, and closure. Leveraging deep expertise in contracts, reimbursement methodologies, and regulatory requirements, the Senior Manager drives timely and equitable outcomes through strategic evaluation and proactive escalation of unresolved cases. Focused on reducing administrative friction and enhancing provider satisfaction, the manager conducts root-cause analyses to address systemic payment issues and implements actionable improvements. As a management-level escalation point, the Senior Manager coordinates cross-functional reviews to align contractual and operational outcomes, ensuring accurate claim adjudication and addressing gaps between contract language and claims configuration. Leads operational reviews and negotiates provider settlements, maintaining rigorous documentation and securing necessary leadership approvals. By developing and inspiring a high-performing team, the Senior Manager fosters a culture of accountability, analytical rigor, and sustained issue resolution, preparing executive summaries for senior leadership and modeling professionalism and consistency in all interactions. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Oversee the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care. Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Requirements

Bachelor's Degree
At least 7 years of extensive experience managing provider appeals, payment disputes, and claim escalations within healthcare or managed care.
At least 5 years of experience in leading, supervising and/or managing staff.
Experience leading teams, projects, initiatives, or cross-functional groups.
Demonstrated experience in contract interpretation, reimbursement methodologies, and regulatory compliance, along with a proven ability to design standardized dispute resolution processes.
Leadership experience in developing high-performing teams and delivering actionable insights to senior management is critical, as is a commitment to professionalism, objectivity, and consistent issue resolution.
Strong skills in root-cause analysis, cross-functional collaboration, and operational review of settlements are essential.
Advance knowledge and understanding in managing provider appeals, payment disputes, and claim escalations within healthcare or managed care environments.
Advance knowledge and understanding of contract interpretation, reimbursement methodologies, and regulatory compliance, as well as the ability to design and implement standardized dispute resolution processes.
Strong analytical skills are required for conducting root-cause analyses and driving operational improvements.
Effective leadership skills, clear communication, and cross-functional collaboration are critical for aligning outcomes and developing high-performing teams.
Consistent professionalism, objectivity, and accountability are foundational to success in this position.
Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.
Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.
Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.
Must have a deep understanding of financial principles.
Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.
Demonstrated ability to make informed decisions.
Strong verbal, written communication and presentation skills.
Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.
Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.
Travel to offsite locations for work required.

Nice To Haves

In lieu of degree, equivalent education and/or experience may be considered.
Master's Degree
Experience with contract configuration and claims adjudication platforms, and a background in negotiating provider settlements.
Advanced proficiency in data analytics and reporting tools.
Knowledge of legal, finance, and compliance processes related to provider disputes is highly valued.
Ability to lead organizational change initiatives, develop feedback mechanisms for continuous improvement, and build strong stakeholder relationships across diverse teams.
Strategic vision skills with the ability to enhance provider satisfaction and operational efficiency.

Responsibilities

Safeguards organizational integrity and fostering collaborative provider relationships. Responsible for the end-to-end management of provider appeals, payment disputes, claim escalations, and complex reimbursement concerns.
By establishing robust, standardized processes for intake, triage, investigation, assignment, resolution, and closure, ensure operational consistency and regulatory compliance across all provider dispute activities.
Strategically evaluates disputes, leveraging deep expertise in contract terms, reimbursement methodologies, claims history, configuration, policy, and regulatory requirements. Through the development of standardized resolution pathways and vigilant monitoring of dispute aging, proactively escalates unresolved cases, ensuring timely and equitable outcomes.
Identifies and eliminates unnecessary administrative friction, driving efficiency in the provider dispute process. Conducts structured root-cause analyses for significant, recurring, or systemic payment issues, transforming insights into actionable improvements that reduce future disputes and enhance provider satisfaction.
Serves as a management-level escalation point, coordinates cross-functional reviews for complex claims and payment issues, aligning contractual and operational outcomes through collaboration with key stakeholders. Ensures that claim adjudication accurately reflects executed contractual terms and approved reimbursement methodologies, swiftly addressing disconnects or operational gaps between contract language and claims configuration.
Orchestrates operational reviews and negotiates non-litigation settlements, maintaining rigorous documentation and ensuring all settlements receive appropriate leadership approvals. This includes tracking settlement rationale, calculations, approvals, and final disposition to uphold transparency and accountability.
Develops and inspires a high-performing team, sets clear performance expectations and fosters a culture of accountability, analytical rigor, and sustained issue resolution. Prepares executive summaries for significant disputes and settlements, equipping senior leadership with actionable insights for strategic decision-making.
Models’ professionalism throughout all internal and external interactions, objectivity, and consistency, ensuring that every engagement reflects the organization’s values and commitment to excellence.
Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develop staff, building technical and problem-solving skills across the team.
Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/or executive management to define, prioritize, and develop projects and programs.
Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
Responsible for overseeing and managing the budgets of their respective departments.
Manages complex projects, engaging and updating key stakeholders, developing timelines, leads others to complete deliverables on time and ensures implementation upon approval.
Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities.
Perform other duties as assigned