Manager, Clinical Escalations

Opportunity Overview:

We are seeking a Manager, Clinical Escalations to join our Clinical Process and Standards team. In this role, you will build and lead Cohere Health's Escalations Program within Clinical Operations. You’ll partner closely with Client Success, Clinical Operations, Compliance, and leadership to ensure provider and/or client escalations are resolved effectively and efficiently while protecting Cohere’s operational integrity and regulatory commitments. The ideal candidate brings strong customer service instincts, a structured approach to program development, and a customer focused presence to effectively manage sensitive escalations.

What you’ll do:

• Stand up the Escalations Program: Design and implement a formal escalation framework, including intake processes, triage criteria, severity classifications, tracking mechanisms, and reporting cadences — transitioning this function from the Client Success team into a dedicated program.

• Triage and manage client and provider complaints: Serve as the primary point of accountability for all incoming escalations, ensuring each is categorized, assigned, and resolved according to defined workflows.

• Ensure follow-up and resolution: Monitor all open escalations to confirm that follow-up actions are performed, completed, and documented. Hold internal teams accountable for timely closure.

• Meet mandatory response times: Track and enforce compliance with all regulatory and contractual response time requirements. Proactively flag risks and implement corrective actions when TATs are at risk.

• Handle executive escalations with care: Manage high-sensitivity escalations involving executive-level clients or providers with discretion, professionalism, and a solutions-oriented approach.

• Escalate proactively within the organization: Ensure Cohere leadership is never caught off guard — provide timely, clear communication to internal leaders on escalations that carry reputational, regulatory, or relationship risk.

• Lead and develop the Escalations Analyst: Manage, coach, and support one direct report responsible for escalation tracking, data analysis, and reporting.

• Report on escalation trends and performance: Develop dashboards and regular reporting to track escalation volume, resolution rates, TAT compliance, root causes, and trends. Use data to drive continuous improvement.

• Collaborate cross-functionally: Partner with Client Success, Clinical Operations, Compliance, Product, Clinical Content, and other teams to address systemic issues surfaced through escalations and improve the overall client and provider experience.

• Develop and maintain escalation documentation: Create and maintain standard operating procedures (SOPs), escalation playbooks, and communication templates.

What you’ll need:

• Bachelor's degree in healthcare

• Active clinical licensure in state of residence (RN, PT/OT/SLP considered)

• 3+ years of experience in utilization management operations

• Experience in external client, provider, and/or member communications

• Knowledge of healthcare regulations and accreditation (CMS, Medicaid, JCAHO)

• Proficiency with spreadsheet functions, including data analysis and drawing quantitative conclusions

• Experience implementing process improvements

• Ability to function independently and navigate ambiguity to build a cross-functional program

• Strong problem-solving skills with a customer focus

• Passion for improving the U.S. healthcare system and helping ensure every patient receives the best care possible

• Familiarity with ticketing or project management software (e.g., CRM, JIRA, Monday.com) is a plus

• Demonstrated success implementing new programs is a plus

• People leadership experience is a plus

• Experience managing escalations in a multi-client or multi-health-plan environment is a plus

• Familiarity with root cause analysis (RCA) methodologies and corrective action plan (CAP) development is a plus

Pay & Perks:

💻 Fully remote opportunity with about 10% travel

🩺 Medical, dental, vision, life, disability insurance, and Employee Assistance Program

📈 401K retirement plan with company match; flexible spending and health savings account

🏝️ Flex Time Off + company holidays

👶 Up to 14 weeks of paid parental leave

🐶 Pet insurance

The salary range for this position is $116,000 to $125,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment.

Interview Process*:

• Connect with Talent Acquisition for a Preliminary Phone Screening

• Meet your Hiring Manager!

• Behavioral Interview(s)

*Subject to change

About Cohere Health:

Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum–including policy, prior authorization, payment accuracy, and more–the company improves collaboration and reduces burden, resulting in up to 8x ROI and 94% provider satisfaction.

With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation, we’re creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately.

Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners.

The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone.

We can’t wait to learn more about you and meet you at Cohere Health!

Equal Opportunity Statement:

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.

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