Senior Denials & Appeals Specialist – Care Management

**About the role** Sprite Health is seeking an experienced denial\-management professional to manage denied claims, appeals, reconsiderations, and Provider Dispute Resolution (PDR) submissions for care management and community\-based healthcare services. This role requires someone who can independently investigate why a claim was denied, determine the appropriate resolution pathway, prepare a well\-supported appeal or dispute, communicate effectively with health plans, and follow the case through to payment or a documented final outcome. **Demonstrated experience resolving denials, appeals, and PDRs is essential. CalAIM Enhanced Care Management (ECM) and Community Supports experience is preferred.** **Key responsibilities** * **Own denial resolution from start to finish:** Review denials, determine root causes, gather supporting evidence, submit the appropriate response, track payer decisions, and verify resulting payments. * **Prepare substantive appeals and PDRs:** Write clear, persuasive submissions supported by claim history, authorizations, service documentation, contracts, payer policies, and proof of timely filing. * **Select the correct resolution pathway:** Determine when a case requires a corrected claim, reconsideration, payment appeal, PDR, authorization follow\-up, or further escalation. * **Investigate complex denials:** Resolve issues involving eligibility, authorization dates and units, provider enrollment, coding, modifiers, place of service, duplicate claims, timely filing, documentation, medical necessity, and payer processing errors. * **Challenge payment discrepancies:** Investigate underpayments, incorrect reimbursement rates, recoupments, and offsets against applicable contracts and supporting records. * **Work directly with health plans:** Communicate with claims departments, provider services, provider relations, authorization teams, and escalation contacts to obtain actionable responses. * **Protect filing deadlines:** Maintain payer\-specific requirements, submission deadlines, proof of receipt, acknowledgment records, follow\-up dates, and escalation schedules. * **Coordinate supporting documentation:** Work with care managers, authorization staff, billing teams, and provider organizations to obtain complete, accurate records. Coordinate clinical justification with qualified clinical staff when needed. * **Maintain an auditable case history:** Document the denial reason, amount at risk, actions taken, supporting evidence, payer communications, next steps, and final disposition. * **Prevent recurring denials:** Identify patterns by payer, provider, service, and denial reason; recommend improvements to billing, authorization, documentation, and system workflows. * **Report outcomes:** Track recovered revenue, appeal and PDR outcomes, unresolved balances, aging, recurring issues, and cases requiring leadership intervention. **Required experience and qualifications** * At least **5 years of relevant healthcare revenue\-cycle experience**, including **3 or more years directly handling denials, appeals, and provider disputes**. * Demonstrated provider\-side experience independently preparing and submitting appeals, reconsiderations, and PDRs—not solely checking claim status or routing cases to other teams. * Experience resolving reimbursement issues for care management, care coordination, behavioral health, home\- and community\-based services, or comparable community\-based healthcare programs. * Strong Medicaid managed care knowledge and experience navigating payer\-specific claims and dispute processes. * Ability to interpret EOBs, electronic remittance advice, claim adjustment reason codes (CARCs), and remittance advice remark codes (RARCs). * Working knowledge of CMS\-1500/837P claims, 835 remittance files, payer portals, clearinghouses, and billing or practice\-management systems. * Ability to interpret provider contracts, reimbursement terms, payer manuals, authorization requirements, and supporting service documentation. * Strong written communication skills, including the ability to construct a factual, evidence\-based argument for overturning a denial. * Strong analytical and organizational skills, with the ability to manage multiple payers, providers, deadlines, and unresolved cases. * Proficiency with Excel or comparable reporting tools. * Sound judgment when handling protected health information and confidential provider records. **Preferred qualifications** * Experience with California Medi\-Cal managed care plans, such as Partnership HealthPlan, IEHP, Health Net, Anthem Blue Cross, Molina, or L.A. Care. * Familiarity with ECM enrollment and consent documentation, Community Supports authorizations, and service\-specific reimbursement requirements. * Knowledge of California provider dispute processes and applicable regulatory escalation pathways. * Experience creating denial\-management procedures, appeal templates, payer reference guides, or staff training. * Relevant revenue\-cycle or coding certification. **What success looks like** * Complete, well\-supported appeals and PDRs submitted within applicable deadlines. * Measurable recovery of denied and underpaid claims. * Reduction in aged, unresolved denial balances. * Clear ownership and documented next steps for every active case. * Fewer repeat denials through improvements to upstream workflows. * Reliable reporting that distinguishes cases awaiting payer action, internal documentation, escalation, or final closure. **Application requirements** Please describe two complex denials you personally resolved, including the denial reason, your investigation, the appeal or PDR approach, and the final outcome. Include the payer types and care settings you have supported and any measurable recovery results. Pay: $30\.00 \- $35\.00 per hour Expected hours: 40\.0 per week Benefits: * Flexible schedule Work Location: Remote