Payor Escalation Specialist

The Payor Escalation Specialist plays a key role in resolving complex and high‑impact payor issues that cannot be handled through routine processes. This role serves as the primary escalation point before issues are elevated to management or executive leadership.

Working closely with the Payor Defense Team and internal partners, the specialist ensures payor disputes are well‑documented, contractually supported, and strategically managed. This position balances strong contract enforcement with maintaining effective and professional payor relationships.

Key Responsibilities

• Act as the primary escalation contact for complex payor issues, including:
• Systemic denials
• Reimbursement disputes
• Audit findings
• Access issues
• Contract violations
• Assess whether issues are ready for escalation and develop clear resolution strategies.
• Communicate directly with payor representatives and leadership to resolve issues prior to management or executive involvement.
• Coordinate escalations with leadership when higher‑level involvement is required.
• Ensure all escalations are supported with complete documentation, analysis, and contract references.
• Track escalation activity, outcomes, and trends for reporting and accountability.
• Identify recurring payor issues and recommend proactive solutions.
• Collaborate with the Contract Compliance Auditor to align findings with escalation strategies.
• Develop and maintain escalation playbooks, frameworks, and internal guidance.
• Educate internal teams on escalation processes and best practices.
• Perform other related duties as needed to support departmental and organizational goals.

Qualifications Required

• Bachelor’s degree in healthcare administration, business, finance, nursing, medical records, or a related field

OR

• A minimum of 7 years of equivalent experience in a related field preferred
• Experience in managed care operations, payor relations, contracting, or revenue cycle leadership
• Experience managing complex payor disputes or escalations

Skills & Competencies

• Strong analytical, organizational, and communication skills
• Ability to clearly explain complex contractual, operational, and regulatory information
• Sound judgment, professionalism, and emotional intelligence
• Strong understanding of managed care principles and contract interpretation
• Ability to work independently as a subject matter expert
• Strong collaboration and relationship‑building skills
• Proficiency with computer applications and reporting tools

Work Environment

• High level of focus and critical thinking required
• Frequent interaction with internal stakeholders and external payor representatives
• Hybrid role with some onsite work expected