Senior Manager, Integrity and Provider Escalation

Job Description A bit about this role:
The Senior Manager of Payment Integrity is responsible for data-driven research and root-cause analyses related to payment integrity provider disputes and escalations to facilitate resolution and drive education in support of Devoted’s collaborative provider relationships. In this role, the Senior Manager directly oversees Payment Integrity disputes and appeals delivery teams. This role will own day-to-day operations and support, including end-to-end queue management, operational timeliness, quality assurance, training, and strict adherence to service level agreements (SLAs).

The Senior Manager partners closely with leadership and operational support teams to ensure edits, audits, and reviews are executed properly while monitoring compliance with organizational and regulatory standards.

• Operational & SLA Management:
  Direct, mentor, and oversee the Payment Integrity (PI) disputes and appeals delivery team, driving daily queue health, turnaround times, quality assurance, and strict SLA compliance across all claim disputes and escalations.
• Dual-Track Subject Matter Expertise:
  Serve as the definitive Subject Matter Expert (SME) on complex billing guidelines, reimbursement policies, and CMS regulations (e.g., NCCI, LCD/NCDs), acting as the primary point of escalation for delivery teams and internal cross-functional partners on high-complexity claims.
• Root-Cause & Trend Analysis:
  Perform granular trend analyses on dispute data—evaluating CPT/HCPCS codes, modifiers, billing taxonomy, facilities, and regions—to identify volume spikes, billing errors, and underlying system or policy root causes.
• Upstream Synergy & Policy Optimization:
  Translate dispute and appeal insights into actionable recommendations for upstream PI edit and audit teams to refine logic, eliminate policy ambiguities, reduce overturn rates, and mitigate future dispute volume over time.
• Leadership Reporting & Escalations:
  Represent Payment Integrity dispute performance to senior leadership through clear operational reporting and trend updates; step in directly to resolve high-priority provider escalations.
• Audit Readiness & Governance:
  Maintain rigorous documentation logs, SOPs, and quality control frameworks for claim research to ensure continuous audit readiness for CMS program audits, state regulatory reviews, and internal compliance evaluations.
• External Provider Enablement:
  Collaborate across clinical, coding, and operational teams to leverage payment integrity dispute findings into targeted external billing guidance, clear policy documentation, and provider education.
• Process Modernization:
  Identify opportunities to leverage AI tools, automation, and LLM-assisted workflows to accelerate research, improve log quality, and streamline daily operational throughput.

• 5+ Years of Healthcare PI & Dispute
  
  Experience:
  
  Proven track record in healthcare payment integrity, provider dispute management, coding/clinical documentation review, or claim audit operations.
• 3+ Years of supervisory or people management experience.
• Deep CMS & Coding Expertise:
  Extensive mastery of CMS regulations governing Medicare Advantage disputes, organization determinations, and auditing protocols, paired with expert-level knowledge of CPT, HCPCS, ICD-10, UB-04, NCCI edits, and NCD/LCD guidelines.
• Balanced SME & Operational Leadership:
  Demonstrated ability to manage operational metrics, queue throughput, and team performance while simultaneously serving as the high-level SME for complex medical record reviews and coding/clinical determinations.
• Root-Cause Analytics & Data Proficiency:
  Strong analytical background in synthesizing claims data, research…