[Hiring] Senior Appeals & Denials Resolution Manager @Big Health

Role Description

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.

Key Responsibilities

• 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.

Qualifications

• Bachelor’s degree in healthcare administration, business, health sciences, or related discipline, or equivalent professional experience.
• 7+ years of progressive experience in healthcare reimbursement, revenue cycle, denial management, or payer appeals, including 3+ years of complex-appeal ownership and 0-2 years of management experience, with demonstrated experience leading operational workflows, managing performance, or overseeing appeals resources.
• Demonstrated record of successfully overturning challenging commercial payer denials, with ability to explain investigative methods and results.
• Working knowledge of commercial payer and Medicare appeal processes, medical policies, CPT/HCPCS coding, remittance advice, denial codes, and reimbursement methodologies.
• Excellent appeal-writing skills, payer communication and escalation judgment, detailed case documentation, and analytical problem-solving.
• Experience designing operational workflows, managing substantial case volumes, and meeting payer-specific timelines with limited supervision.
• Strong analytical skills, including data analysis and resource management.

Preferred Qualifications

• Experience in behavioral health, digital health, medical devices, specialty healthcare, or emerging technologies.
• Familiarity with appeals involving newer HCPCS codes, FDA-cleared therapies, investigational policies, and independent external review.
• Experience transitioning outsourced appeals in-house or implementing AI-supported revenue cycle software.
• Relevant credentials such as CPC, CPMA, or CRCR; experience mentoring or supervising appeals staff.

Benefits

• $120,000 - $140,000 a year.
• The US total compensation range for this full-time position is $120,000 - $140,000. This range reflects the target total compensation for the role and may include a combination of base salary, bonus, or variable pay, equity, and benefits.
• Our compensation ranges are determined by role, level, and location. The range displayed on each job posting reflects the minimum and maximum target total compensation for hires across all US locations. Within the range, final candidate-specific compensation is determined by additional factors, including job-related skills, experience, and relevant education or training.

Company Description

We at Big Health are on a mission to bring millions back to good mental health, in order to do so, we need to reflect the diversity of those we intend to serve. We’re an equal opportunity employer dedicated to building a culturally and experientially diverse team that leads with empathy and respect. Additionally, we will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the San Francisco Fair Chance Ordinance.

Big Health participates in E-Verify for all new hires in the United States.

Big Health may use artificial intelligence tools (AI) to support certain US hiring processes, such as reviewing applications, analyzing resumes, or assessing responses. These tools may assist our US recruitment team, but do not replace our human judgment. Our recruitment process is supervised by humans and final hiring determinations are ultimately made by humans. Big Health does not use AI to support its UK hiring processes.