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. It’s 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: Bachelor’s 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.

.

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.