Payor Escalation Specialist

Bronson Healthcare

8d•Hybrid

About The Position

The Payor Escalation Specialist is responsible for leading and coordinating the resolution of complex, high impact payor issues that require formal escalation on behalf of the Managed Care Department. This position is accountable for managing payor disputes that extend beyond routine operational workflows, including systemic denials, reimbursement issues, audit disputes, access concerns, and violations of contractual obligations. The Payor Escalation Specialist serves as the primary point of escalation prior to involvement of management or executive leadership. This position works collaboratively within the Payor Defense Team and across the organization to assess escalation readiness, develop escalation strategies, and manage communications with payor contacts and leadership. The Payor Escalation Specialist is expected to engage directly with appropriate payor representatives to resolve concerns, exercising sound judgment, professionalism, and contract-based advocacy. Escalations requiring higher level involvement will be coordinated with management or leadership as appropriate. The Payor Escalation Specialist will take initiative to understand the root cause of escalated issues, ensure supporting documentation and analysis are complete, and manage escalations through resolution. This role functions as an individual contributor with subject matter expert authority and will serve as a lead in payor escalation efforts, escalation framework development, and issue tracking. The role balances assertive enforcement of contractual rights with effective payor relationship stewardship. The Payor Escalation Specialist shall maintain subject matter expertise related to managed care contract provisions, dispute resolution pathways, escalation protocols, payor organizational structures, and applicable regulatory statutes as incorporated into contractual language. This position is accountable for developing and maintaining escalation playbooks, tracking mechanisms, and internal guidance to ensure consistency, transparency, and accountability across payor relationships. Position is a hybrid role with expectations of onsite work.

Requirements

Bachelor's Degree in a related field such as healthcare administration, business, finance, nursing, or medical records OR experience equivalent to this degree of at least 7 years in a related field.
Strong analytical, organizational, and communication skills are required, with the ability to synthesize complex contractual, operational, and regulatory information into clear escalation narratives.
Demonstrates sound judgment, professionalism, and emotional intelligence when managing sensitive and high impact payor issues.
Strong understanding of managed care principles, contract interpretation, and payor operational structures.
Ability to work independently, serve as a subject matter expert, and lead escalation efforts within a matrix team.
Proficiency in computer applications and reporting tools is required.
Work produces high levels of mental demand requiring sustained focus, coordination, and professional communication.
The role involves frequent interaction with internal stakeholders and external payor representatives.
Excellent verbal and written communication skills are essential, including the ability to communicate effectively with payor leadership and internal executives.
Strong human relations skills and the ability to work constructively across departments are required.

Nice To Haves

Background in managed care operations, payor relations, contracting, or revenue cycle leadership is strongly preferred.
Experience managing complex payor disputes or escalations is preferred.

Responsibilities

Serves as the primary point of escalation for complex payor issues requiring formal intervention.
Assesses escalation readiness and develops escalation strategies in collaboration with Payor Defense Team members.
Engages directly with payor contacts to resolve escalated concerns prior to management or executive involvement.
Coordinates escalation efforts with management or leadership when appropriate.
Ensures escalations are supported by complete documentation, analysis, and contractual references.
Tracks escalation activity, outcomes, and trends to support accountability and leadership reporting.
Identifies recurring payor issues and systemic risks requiring proactive intervention.
Collaborates closely with the Contract Compliance Auditor to align compliance findings with escalation strategies.
Develops and maintains escalation playbooks, frameworks, and internal guidance.
Educates internal teams on escalation processes, expectations, and best practices.
Performs other duties as assigned to support departmental operations, organizational priorities, and the needs of leadership.