Senior Appeals & Denials Resolution Manager
Posted Updated
Description
Our Mission
At Big Health, our mission is to help millions back to good mental health by providing fully digital, non-drug options for the most common mental health conditions. Our FDA-cleared digital therapeutics—SleepioRx for insomnia and DaylightRx Treatment for anxiety—guide patients through first-line recommended, evidence-based cognitive and behavioral therapy anytime, anywhere. Our digital program, Spark Direct, helps to reduce the impact of persistent depressive symptoms.
In pursuit of our mission, we’ve pioneered the first at-scale digital therapeutic business model in partnership with some of the most prominent global healthcare organizations, including leading Fortune 500 healthcare companies and Scotland’s NHS. Through product innovation, robust clinical evaluation, and a commitment to equity at scale, we are designing the next generation of medicine and the future of mental health care.
Our Vision
Over the next 5-10 years, we believe digital therapeutics will transform the delivery of healthcare worldwide by providing access to safe and effective evidence-based treatments. Big Health is positioned to take the lead in this transformation.
Big Health is a remote-first company, and this role can be based anywhere in the US.
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.
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.
Required Skills and Experience
- Required
- 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
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.
Skills
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- We are committed to providing reasonable accommodations to applicants with disabilities. If you need assistance or an accommodation due to a disability for any part of the application or hiring process, you can, but are not at all required, to let us know below. Examples of reasonable accommodations include but are not limited to: modifying the application process or work procedures, providing documents in alternate formats, using a sign language interpreter, and using specialized equipment. Do you require an accommodation to participate in the application or interview process?
- Federal law requires employers to provide reasonable accommodations to qualified individuals with disabilities. Are you able to perform the essential functions of this position, with or without reasonable accommodation?
- Are you legally authorized to work in the United States? optional
- Will you now or in the future require sponsorship for employment visa status? optional