Manager, Clinical Escalations

We are seeking a Manager, Clinical Escalations to join our Clinical Process and Standards team. In this role, you will build and lead Cohere Health's Escalations Program within Clinical Operations. You’ll partner closely with Client Success, Clinical Operations, Compliance, and leadership to ensure provider and/or client escalations are resolved effectively and efficiently while protecting Cohere’s operational integrity and regulatory commitments. The ideal candidate brings strong customer service instincts, a structured approach to program development, and a customer focused presence to effectively manage sensitive escalations.

What you’ll do:

• Stand up the Escalations Program:
  Design and implement a formal escalation framework, including intake processes, triage criteria, severity classifications, tracking mechanisms, and reporting cadences — transitioning this function from the Client Success team into a dedicated program.
• Triage and manage client and provider complaints:
  Serve as the primary point of accountability for all incoming escalations, ensuring each is categorized, assigned, and resolved according to defined workflows.
• Ensure follow-up and resolution:
  Monitor all open escalations to confirm that follow-up actions are performed, completed, and documented. Hold internal teams accountable for timely closure.
• Meet mandatory response times:
  Track and enforce compliance with all regulatory and contractual response time requirements. Proactively flag risks and implement corrective actions when TATs are at risk.
• Handle executive escalations with care:
  Manage high-sensitivity escalations involving executive-level clients or providers with discretion, professionalism, and a solutions-oriented approach.
• Escalate proactively within the organization:
  Ensure Cohere leadership is never caught off guard — provide timely, clear communication to internal leaders on escalations that carry reputational, regulatory, or relationship risk.
• Lead and develop the Escalations Analyst:
  Manage, coach, and support one direct report responsible for escalation tracking, data analysis, and reporting.
• Report on escalation trends and performance:
  Develop dashboards and regular reporting to track escalation volume, resolution rates, TAT compliance, root causes, and trends. Use data to drive continuous improvement.
• Collaborate cross-functionally:
  Partner with Client Success, Clinical Operations, Compliance, Product, Clinical Content, and other teams to address systemic issues surfaced through escalations and improve the overall client and provider experience.
• Develop and maintain escalation documentation:
  Create and maintain standard operating procedures (SOPs), escalation playbooks, and communication templates.

What you’ll need:

• Bachelor's degree in healthcare
• Active clinical licensure in state of residence (RN, PT/OT/SLP considered)
• 3+ years of experience in utilization management operations
• Experience in external client, provider, and/or member communications
• Knowledge of healthcare regulations and accreditation (CMS, Medicaid, JCAHO)
• Proficiency with spreadsheet functions, including data analysis and drawing quantitative conclusions
• Experience implementing process improvements
• Ability to function independently and navigate ambiguity to build a cross-functional program
• Strong problem-solving skills with a customer focus
• Passion for improving the U.S. healthcare system and helping ensure every patient receives the best care possible
• Familiarity with ticketing or project management software (e.g., CRM, JIRA, ) is a plus
• Demonstrated success implementing new programs is a plus
• People leadership experience is a plus
• Experience managing escalations in a multi-client or multi-health-plan environment is a plus
• Familiarity with root…