Senior Appeals & Denials Resolution Manager

Position Summary

Big Health is seeking an experienced, results-driven Senior Appeals & Denials Resolution Manager to establish and lead payer appeals and denial resolution operations. This role will independently investigate difficult denials, develop persuasive evidence-based appeals, engage payer reviewers and decision-makers, and own cases through appropriate levels of review. They will also design scalable workflows, documentation standards, reporting, and quality controls, using AI-enabled technology to improve efficiency while maintaining human oversight.

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.