Claims Resolution Manager

Company Overview:

Upward Health is an in-home, multidisciplinary medical group providing 24/7 whole-person care. Our clinical team treats physical, behavioral, and social health needs when and where a patient needs help. Everyone on our team from our doctors, nurses, and Care Specialists to our HR, Technology, and Business Services staff are driven by a desire to improve the lives of our patients. We are able to treat a wide range of needs everything from addressing poorly controlled blood sugar to combatting anxiety to accessing medically tailored meals because we know that health requires care for the whole person. Its no wonder 98% of patients report being fully satisfied with Upward Health!

Job Title & Role Description:

The Claims Resolution Manager leads the end-to-end process of resolving outstanding and denied medical claims. This role ensures timely reimbursement, compliance with payer requirements, and optimal revenue cycle performance. The ideal candidate is a problem solver who blends deep knowledge of healthcare revenue cycle operations with team-building and payer relationship skills.

Key Responsibilities:

• Claims Oversight & Resolution
  • Direct and manage the claims resolution team to ensure prompt follow-up on unpaid, denied, or underpaid claims.
  • Analyze payer trends to identify root causes of denials and implement proactive corrective actions.
  • Oversee appeals, resubmissions, and secondary claims to maximize recoveries.
• Process & Performance Management
  • Establish and monitor key performance indicators (KPIs) such as days in A/R, denial rate, and cash collections.
  • Develop standardized workflows and best practices to drive efficiency and accuracy.
  • Partner with Revenue Cycle, Coding, and Clinical Operations teams to prevent rework and reduce avoidable denials.
• Compliance & Payer Relations
  • Ensure all activities comply with federal and state regulations, payer contracts, and HIPAA requirements.
  • Serve as the escalation point for payer disputes and foster strong relationships with payers to facilitate timely resolution.
• Leadership & Collaboration
  • Recruit, train, and mentor claims resolution staff.
  • Collaborate with Finance, Technology, and Market Operations to support company-wide revenue cycle initiatives.

Qualifications:

• Experience: 5+ years in medical claims resolution, revenue cycle management, or payer operations, with at least 2 years in a leadership or supervisory capacity.
• Knowledge: Expertise in Medicare, Medicaid, and commercial payer rules, including value-based and risk-bearing arrangements.
• Skills:
  • Advanced Microsoft Excel proficiency, including pivot tables, v-lookups, and complex formula building for data analysis and reporting.
  • Strong analytical and problem-solving abilities.
  • Excellent communication and negotiation skills.
  • Proficiency in EHR/PM and claims management systems.
• Preferred: Experience with Salesforce Health Cloud and Athenahealth (Athena) practice management/EHR systems.
• Education: Bachelors degree in healthcare administration, finance, or related field (or equivalent experience).

Key Competencies:

• Results-oriented with a continuous improvement mindset.
• Skilled at interpreting complex payer policies and regulatory guidance.
• Team-oriented leader who models integrity and accountability.
• Ability to thrive in a fast-growing, mission-driven healthcare organization.

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Upward Health is proud to be an equal opportunity employer. We are committed to attracting, retaining, and maximizing the performance of a diverse and inclusive workforce. This job description is a general outline of duties performed and is not to be misconstrued as encompassing all duties performed within the position.

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