Senior Appeals & Denials Resolution Manager

Appeals Management & Denial Resolution

Manage end-to-end appeals operations from denial intake through resolution, including prioritization, workload allocation, quality oversight, and timely execution of initial and second-level appeals, reconsiderations, and external reviews when applicable.

Personally handle complex medical necessity, investigational/experimental, noncovered service, coding, and reimbursement-related denials.

Build 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; ensure timely and accurate submissions.

Payer Investigation & Escalation

Communicate directly with payer claims, provider relations, medical policy, utilization management, and clinical review teams as appropriate.

Ask probing questions to identify the actual basis for denials or upheld decisions and determine what evidence, review, or corrective action could 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.

Operations & Process Development

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.

AI-Enabled Appeals Operations

Serve as operational owner for AI-supported appeals workflows, including draft generation, document review, tracking, and routine payer follow-up.

Independently review AI-produced outputs for factual accuracy, evidence quality, completeness, and payer-specific requirements.

Retain human responsibility for appeal submission, complex payer engagement, judgment-intensive exceptions, and quality assurance.

Identify workflow improvements while adhering to privacy, security, and compliance requirements.

Performance, Reporting & Leadership

• 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 the broader access and reimbursement strategy.

Provide regular reporting to Market Access leadership and work closely with Clinical, Legal, Finance, and provider-facing teams.

Serve as the operational leader and primary subject-matter expert for appeals and denial resolution, accountable for 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.