Job Description

The Enterprise Payer Escalation Specialist is responsible for resolving high-impact, escalation-eligible claims that require advanced intervention beyond standard A/R follow-up. This includes claims with systemic payer issues, contractual payment discrepancies, and prolonged processing delays. This role serves as the final escalation point between Revenue Cycle Operations and Managed Care, ensuring appropriate use of escalation channels, enforcing payer contract compliance, and driving timely revenue recovery. The specialist also plays a key role in identifying root causes and escalation triggers to prevent recurrence and improve front-end and back-end processes.

Responsibilities:

· Escalation Management & Resolution

• Review and action escalation-eligible scenarios, including but not limited to:
• Valid authorization on file but denied for no/invalid authorization
• Claims submitted multiple times but not on payer file
• Appeals submitted with no payer response within regulatory timeframe
• Underpayments not aligned to contract terms (e.g., APC, fee schedule variances)
• Excessive processing delays beyond payer standard turnaround time
• Execute advanced follow-up using escalation pathways (payer reps, account managers, formal disputes).
• Ensure all escalations meet defined criteria and documentation standards prior to submission.

· Root Cause Identification & Trend Analysis

• Track and categorize escalation drivers (e.g., auth issues, payer processing failures, system gaps).
• Identify repeat payer behavior or systemic breakdowns.
• Provide structured feedback to Revenue Cycle, Managed Care, and Operations teams.
• Support development of preventative actions and SOP updates based on trending issues.

· Contractual Enforcement & Payment Integrity

• Validate claims against payer contracts, reimbursement methodologies, and regulatory guidelines.
• Build clear, defensible cases to support formal escalation and dispute resolution.
• Partner with Managed Care to address payer non-compliance trends and escalation patterns.
• Ensure all recoveries are aligned with contractual and audit requirements.

· Cross-Functional Coordination

• Act as liaison between: Central Billing Office (CBO), Managed Care, Coding and Clinical Documentation teams.
• Provide clear escalation criteria guidance to ensure appropriate case selection.
• Support education efforts to reduce non-eligible escalations and rework.

· Documentation & Audit Readiness

• Maintain detailed documentation of: Escalation trigger, Actions taken, Payer responses, Final resolution.
• Ensure all accounts are audit-ready and defensible.
• Contribute to development and refinement of payer escalation job aids, decision trees, and workflows.

Required Experience:

Requirements:

• Education: Bachelor’s degree in Healthcare Administration, Business, or a related field (or equivalent operational experience).
• Experience: 3-5+ years of healthcare revenue cycle experience, specifically in Complex denial resolution, Payer escalations or payer relations, Managed care, or contract reimbursement
• Demonstrated experience handling high-dollar or complex accounts requiring escalation.
• Regulatory Knowledge: Deep understanding of: Medicare/Medicaid guidelines, Coordination of Benefits, CPT/ICD coding, Appeals, and dispute process.
• Familiarity with payer turnaround times, escalation thresholds, and regulatory response requirements.
• Communication: Exceptional verbal and written communication skills with the ability to Clearly articulate escalation rationale, negotiate and influence payer outcomes, escalate internally with precision and supporting evidence.
• Highly analytical with a focus on root cause identification and resolution.
• Technical Skills: Proficiency in one or more of the Patient Accounting Software’s utilized: Advantx, HST, SIS Complete, Meditech, Cerner.
• Familiarity with clearinghouses and payer portals: NThrive, Waystar preferred.
• Advanced Excel skills for tracking, trending, and reporting escalation data preferred.