Senior Manager, Payment Integrity COE Rework & Escalations

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The Senior Manager, Payment Integrity COE Rework & Escalations provides centralized program leadership for the intake, tracking, coordination, reporting, and resolution of rework and escalations across the Payment Integrity Center of Excellence.

Rework & Escalation Portfolio Management Own the centralized portfolio of Payment Integrity rework items and escalations, including intake, categorization, prioritization, status management, aging, dependencies, risks, decisions, and closure evidence.

• Maintain a consistent source of truth for active work, ensuring each item has a defined business owner, accountable action owner, target date, current status, next step, and escalation path.
• Coordinate multiple concurrent workstreams and follow up on commitments to sustain momentum, remove barriers, and prevent unresolved items from becoming operational risks.
• Establish criteria and working norms for intake, triage, prioritization, handoffs, escalation, closure, and post-implementation monitoring.

Cross-Functional Coordination & Issue Resolution Lead structured working sessions with business and technical partners to clarify the issue, scope, impact, root cause, interim controls, corrective actions, and decision needs.

• Connect the appropriate stakeholders across functional boundaries and coordinate activities when resolution requires multiple teams, vendors, systems, or processes.
• Identify stalled work, conflicting priorities, unclear ownership, resource constraints, and unresolved dependencies; elevate decision points with clear options and recommendations.
• Support sensitive or high-impact escalations with disciplined documentation, neutral facilitation, and timely communication.

Reporting, Metrics & Executive Visibility Develop and maintain recurring dashboards, scorecards, portfolio summaries, aging reports, risk views, and leadership updates for rework and escalation activity.

• Define meaningful measures for intake volume, backlog, aging, cycle time, on-time actions, closure rate, recurrence, financial or operational impact, and other agreed performance indicators.
• Synthesize detailed updates into concise, decision-ready reporting that highlights progress, emerging trends, exceptions, risks, required decisions, and accountable owners.
• Ensure reporting definitions, data sources, status criteria, and calculation methods are documented and applied consistently.

Root Cause, Corrective Action & Rework Reduction Partner with operational owners and subject matter experts to document root causes, contributing factors, failure points, and control gaps using practical process-improvement methods.

• Track corrective and preventive actions through implementation, validation, and sustained closure rather than administrative completion alone.
• Analyze patterns across rework and escalation activity to identify repeat drivers, systemic issues, high-friction handoffs, and opportunities for standardization or automation.
• Translate lessons learned into process, training, control, communication, governance, or technology recommendations.

Governance & Operating Rhythm Design and facilitate a tiered governance cadence for working teams, functional leaders, and executive stakeholders, with clear agendas, pre-reads, decisions, actions, and follow-up.

• Maintain decision logs, action registers, risk and issue logs, milestone plans, and escalation records with appropriate version control and auditability.
• Develop standard templates, definitions, workflows, and job aids that improve consistency across the PI COE rework and escalation lifecycle.
• Promote accountability through transparent reporting, timely follow-up, defined service expectations, and fact-based escalation.

Stakeholder Communication & Change Enablement Build trusted partnerships with leaders, process owners, analysts, project teams, and external partners involved in rework prevention and escalation resolution.

• Prepare executive summaries, briefing materials, talking points, and recommendations tailored to the audience and decision required.
• Coordinate communication and readiness activities for process changes resulting from corrective actions, including stakeholder alignment, documentation, training, and transition support.
• Encourage a collaborative, no-blame approach that focuses on facts, accountability, sustainable fixes, and measurable outcomes.

Team Leadership & Capability Building Lead, coach, and develop assigned employees or contractors supporting portfolio tracking, analysis, reporting, or coordination.

• Set clear expectations, prioritize work, review deliverables, and build repeatable capabilities that improve quality, responsiveness, and stakeholder experience.
• Create an inclusive environment that values transparency, disciplined execution, continuous improvement, and professional growth.

Key Deliverables

• Centralized rework and escalation tracker with clear ownership, milestones, aging, risk, impact, and closure evidence.
• Recurring operational and executive-level portfolio reporting, including trends, exceptions, decisions, and recommended actions.
• Governance calendar and meeting artifacts, including agendas, pre-reads, action logs, decision logs, and follow-up summaries.
• Root-cause and corrective-action documentation for priority items, with validation of implemented solutions.
• Standard intake, triage, prioritization, escalation, reporting, and closure practices for the PI COE.
• Leadership-ready summaries of portfolio health, resource or dependency constraints, and opportunities to reduce recurring rework.

Required Qualifications

• 7-10 years of progressive experience in program, project management, process improvement, audit, provider reimbursement, analytics.
• Demonstrated experience coordinating complex, cross-functional initiatives with multiple owners, dependencies, and competing priorities.
• Strong ability to build and maintain trackers, action plans, dashboards, scorecards, executive summaries, and governance materials.
• Experience using data to identify trends, explain portfolio health, surface risk, and support prioritization and decision making.
• Excellent written, verbal, facilitation, organization, and presentation skills.
• Ability to establish structure in ambiguous situations, work independently, follow through on commitments, and appropriately escalate barriers.
• Proven ability to influence without direct authority and build productive relationships in a matrixed organization.
• Working knowledge of healthcare claims, payment integrity, reimbursement, audit, recovery, or related operational processes.

Preferred Qualifications

• Experience with Commercial, Medicare, Medicaid, Marketplace, or other healthcare payment models.
• Experience leading rework reduction, escalation management, root-cause analysis, corrective-action, operational governance, or continuous-improvement programs.
• Advanced proficiency with Microsoft Excel, PowerPoint, Word, Teams, and SharePoint; experience with Power BI, Visio, Planner, or comparable workflow and reporting tools.
• Experience coordinating vendor-related issues, service-level performance, implementation risks, or cross-enterprise handoffs.
• Knowledge of Lean, Six Sigma, SIPOC, RACI, ADKAR, Agile, or other structured process, change, and project-management practices.
• Professional certification such as CPC, CCS, CPMA, CFE, AHFI, PMP, Lean Six Sigma, or a related credential.

Education

• Bachelor's degree or equivalent combination of education and relevant experience.

Pay Range

• $75,400.00 - $199,144.00