Manager, Advocacy & Dispute Resolution

Summary
The Manager, (Medical Bill) Advocacy & Dispute Resolution is accountable for the end-to-end design, operation, and performance of provider payment inquiry and disputes as well as the member balance bill Advocacy Program. This leader manages a team of Negotiators, Paralegals, and Member Bill Advocates whose mission is to protect members from unexpected out-of-network charges and to resolve provider payment inquiries and disputes. The Manager ensures the program operates in compliance with the organization’s sharing program guidelines, oversees delegated third-party vendor performance against contracted service levels — including Zelis Healthcare (or other contracted vendor) for delegated provider inquiry and dispute response — delivers measurable financial protection to plan members, and provides data-driven program insights to plan leadership. The role requires equal strength in people leadership, vendor management, regulatory knowledge, operational execution, and stakeholder communication.
Essential Duties and Responsibilities
Program Leadership & Strategy

Establish and continuously improve program policies, procedures, workflows, and quality standards for the full advocacy case lifecycle, including balance bill resolution, provider payment inquiries, and provider payment disputes
Define program KPIs and success metrics in collaboration with plan leadership; lead quarterly business reviews and deliver monthly performance dashboards
Develop and maintain a risk register for high-dollar, legally complex, or member-sensitive cases; present risk summary to VP quarterly
Design and implement the staffing ramp strategy using the range model, activating additional FTEs when defined monthly case thresholds are sustained for 60+ days

People Leadership

Provide effective management of staffing levels, performance, coaching, and development of member advocates, paralegals, negotiators and other Advocacy Team support roles
Conduct regular 1:1 meeting with team members to ensure coaching, performance feedback and conflict resolution is addressed timely
Design and deliver onboarding and training programs in coordination with the Training Team to ensure effective knowledge transfer, cross-functional education, and delivered quality to members and providers
Designate and support embedded triage team leads to maintain effective day-to-day supervision
Case Oversight & Escalation
Review all open cases weekly to ensure compliance with resolution timelines, documentation standards, and communication requirements
Serve as primary escalation authority for cases involving legal action, active collections, media attention, member disputes, or regulatory inquiries
Authorize negotiation settlement parameters above negotiation-defined thresholds and approve cases proceeding to alternative dispute resolution or external legal counsel

Provider Payment Inquiries & Disputes

Establish and maintain policies, procedures, and quality standards covering the full lifecycle of provider payment inquiries and disputes
Define inquiry response-time and dispute resolution targets; align internal standards to vendor and contract standards to deliver consistent provider and member experiences
Review aged or unresolved payment disputes regularly and serve as primary escalation point for high-dollar, multi-party, member sensitive, or precedent-setting disputes
Track inquiry and dispute volume, resolution rates, average closure time, and root-cause categories; identify recurring patterns and route systemic issues to Claims, Network Management, or Provider Relations for upstream correction
Authorize settlement parameters and policy exceptions for disputes that exceed standard delegated authority thresholds

Delegated Vendor Oversight

Oversee vendor performance against contracted service level agreements related to provider payment inquiry and dispute response; including response-time SLAs, dispute resolution timelines, and escalation-handling commitments
Monitor vendor response-time performance, inquiry closure rate, and dispute aging through scheduled operational reviews and the contracted reporting cadence
Serve as the organization’s primary internal escalation point for vendor-handled inquiries and disputes that require sharing-ministry-side decisioning, policy interpretation, or settlement authority above vendor’s delegated threshold
Coordinate corrective-action plans with vendors when performance falls below contracted service levels; document remediation, track to closure, and verify return to compliance
Conduct quarterly contract performance reviews with vendors; document SLA performance, surface vendor capacity or service-level concerns, and recommend renewal, renegotiation, or replacement actions to plan leadership and Vendor Management
Maintain shared documentation between the internal advocacy team and vendor covering case-handoff criteria, escalation protocols, settlement authority limits, and reporting standards

Regulatory Compliance

Ensure advocacy program activities comply with the organization’s sharing program guidelines, applicable laws, and required plan documents and disclosures
Coordinate with Compliance on internal and external audits, correction action plans, and any regulatory reporting
Contribute to the exercise and expression of Christian Care Ministry’s beliefs

Stakeholder Relations & Reporting

Serve as the advocacy program’s primary liaison to Needs Processing, Network Management, Provider Relations, Member Services, Finance, Compliance and Legal departments
Present program performance results — including delegated-vendor performance — to plan leadership, the board of directors, and employer or member-group sponsors on a quarterly basis
Manage vendor relationships for third-party arbitration platforms, legal research subscriptions, coding review services, and the vendor healthcare delegation
All other duties as assigned

Essential Skills & Abilities

Demonstrated skill and subject matter expertise of provider payment dispute resolution, member billing protections, and applicable state laws affecting member medical billing
Proven ability to manage delegated third-party vendor performance against contract service levels, including SLA monitoring, correction-action management, and escalation handling
Proficient with case/customer management systems (such as Salesforce Health Cloud)
Proficient with Microsoft Office Suite (Word, Excel, Outlook, PowerPoint, Teams)
Strong Analytics skill – able to create, manage, and easily read complex data reporting and translate it to meaningful insights
Communication skill – able to effectively produce and communicate in written, digital, and oral formats messages that motivate others to action across wide audiences (including executive levels)
Proven ability to manage cross-functional relationships in a regulated environment
Knowledge of Zelis Healthcare standards and operations
Familiarity with Hybrid Multi-Band or multi-tier provider network plan/program structures
Familiarity with healthcare sharing operating models, member sharing guidelines, and shared-eligibility determinations

Core Competencies/Demonstrable Behaviors

Member First – exhibits full commitment to serving members and/or clients by prioritizing their needs first in alignment with our program’s purpose. This commitment is demonstrated through understanding of the program(s), provided through quality and timely service while exercising empathy in every interaction. Every CCM employee shares responsibility to steward resources faithfully, removing barriers to understanding, and creating accessible, connected, and Christ-centered experiences.
Humble – demonstrates Christ-Centered humility by honoring others, accepting feedback, and prioritizing collective success over individual recognition
Hungry – exhibits initiative, perseverance, and commitment to serving God through excellence. Demonstrates passion for personal and organizational growth while diligently advancing the mission of Christian Care Ministry
Smart – shows relational and emotional intelligence, communicates effectively, collaborates harmoniously, and reads social cues with grace and discernment
Leadership – ability to effectively lead cohesive, unified, high performing teams

Education and/or Experience

Bachelor’s degree in Healthcare Administration, Business Administration, Public Health, or a closely related field; Masters’ degree in Healthcare Administration, Business Administration, or Juris Doctorate (JD) preferred
Minimum 5 years of experience in health plan operations, healthcare sharing ministry operations, member services, provider relations, and/or managed care required; preference given to those with experience in balance billing advocacy, provider payment resolution, or third-party arbitration proceedings experience
Minimum 2 years of direct people management or team lead experience required
Direct experience managing or overseeing a Zelis Healthcare delegation or comparable payment-integrity/provider dispute vendor relationship required
Certified Managed Care Professional (CMCP) or equivalent managed care certification preferred
Experience managing a team in a contact center, appeals & grievance, or provider dispute environment preferred

Supervisory Responsibilities
This job has supervisory responsibilities
Travel
This role may require occasional travel within the US 1-4 times per year