Manager -Executive Escalations

Duties and Responsibilities

• Lead, coach, and develop a team of Executive Escalation Specialists responsible for end-to-end resolution of complex medical and dental escalations.
• Establish clear performance expectations, conduct performance reviews, and provide ongoing feedback and development planning.
• Ensure appropriate workload distribution, coverage, and escalation protocols to meet service level and quality expectations.
• Foster a culture of professionalism, accountability, discretion, and strong member advocacy.
• Provide oversight and guidance on the most sensitive, complex, or high-risk escalations, including OPM grievances, leadership-referred cases, and compliance concerns.
• Serve as a management escalation point for cases requiring advanced judgment or executive-level communication.
• Ensure consistent, accurate, and empathetic communication with members, providers, senior leaders, and external stakeholders.
• Establish and maintain investigative standards for root cause analysis, including claims review, eligibility validation, audit of calls and correspondence, and process flows.
• Ensure escalations are resolved accurately, compliantly, and with long-term systemic solutions in mind.
• Apply sound judgment to balance member experience, regulatory requirements, contractual obligations, and reputational risk.
• Partner closely with operations, pharmacy, dental, customer service, and vendors to resolve escalations and mitigate risk.
• Lead or participate in cross-functional working sessions addressing systemic issues surfaced through executive escalations.
• Oversee tracking, reporting, and analysis of executive-level escalations, trends, and outcomes.
• Identify recurring issues and systemic breakdowns in the member journey.
• Translate insights into actionable recommendations to improve processes, claims accuracy, and customer experience.

Investigation, Quality & Risk Management

• Establish and maintain investigative standards for root cause analysis, including claims review, eligibility validation, audit of calls and correspondence, and process flows.
• Ensure escalations are resolved accurately, compliantly, and with long-term systemic solutions in mind.
• Apply sound judgment to balance member experience, regulatory requirements, contractual obligations, and reputational risk.

Reporting, Trends & Continuous Improvement

• Oversee tracking, reporting, and analysis of executive-level escalations, trends, and outcomes.
• Identify recurring issues and systemic breakdowns in the member journey.
• Translate insights into actionable recommendations to improve processes, claims accuracy, and customer experience.

Knowledge, Skills, and Abilities

• Bachelor’s degree in a related field required.
• 5-8 years of experience in a medical and/or dental health plan environment.
• Minimum of 3 years of people management experience, preferably leading teams handling complex escalations or investigations.
• Minimum of 2 years of demonstrated experience in implementing Lean management principles and executing process improvement initiatives.
• Extensive knowledge of medical terminology, claims adjudication processes, and regulatory considerations.
• Demonstrated ability to lead, coach, and develop high-performing teams.
• Advanced analytical, investigative, and critical-thinking skills.
• Exceptional written and verbal communication skills, including executive-level correspondence.
• Demonstrated ability to lead, coach, and develop high-performing teams.
• Strong judgment in managing sensitive situations and reputational risk.
• Ability to summarize and present insights using Excel, PowerPoint, and/or Power BI.

Work-at-home requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Lateness (ping) response time lower than 80 ms.
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.