Manager, Payer Rules – Revenue Cycle Optimization

This is a fully remote position, open to applicants in United States.

📋 Description

• Lead, mentor, and supervise a team of three full-time employees (FTEs).

• Set priorities, distribute tasks, monitor quality and productivity, enhance team skills, and ensure the timely execution of payer rule and contract implementation requests.

• Manage operational readiness for new payer contracts, renewals, amendments, and updates.

• Convert payer contracts, reimbursement policies, and billing guidelines into system rules, business requirements, standard operating procedures, and controls throughout the revenue cycle.

• Maintain accuracy and oversee the upkeep of payer-specific configurations within Brightree and InRule.

• Collaborate with IT, system administrators, vendors, and clearinghouses on specifications, configuration adjustments, user acceptance testing, validation, and troubleshooting.

• Establish governance for the intake, prioritization, approval, documentation, auditing, and validation of payer rule modifications.

• Track updates to Medicare, Medicaid, Medicare Advantage, commercial payer, and manufacturer policies, and communicate their impacts.

• Investigate discrepancies between contracted requirements, system configurations, and payer adjudications or reimbursements.

• Analyze denials, rejections, unbilled claims, underpayments, and reimbursement differences to pinpoint gaps and prioritize remediation efforts.

• Implement automated controls and payer-specific pre-bill edits.

• Coordinate readiness, testing, training, and communication for payer rule changes; escalate risks and ensure that gaps are addressed.

• Support Brightree transformation, integrations, and initiatives for enterprise standardization.

• Develop metrics and report on implementation timeliness, configuration accuracy, denial trends, backlog, and improvements in the revenue cycle.

• Oversee the execution of policies and procedures.

• Ensure that Payer Rules FTEs adhere to guidelines and maintain compliance.

⛳️ Requirements

• Bachelor's degree in healthcare administration, Business, Finance, Information Systems, or a related field, or equivalent relevant experience is preferred.

• At least 5 years of experience in healthcare revenue cycle, payer operations, reimbursement, billing systems, or payer rules is preferred.

• Proven experience in leadership or staff supervision.

• In-depth knowledge of payer contractual and billing requirements, claims processing, denial management, and the ability to translate business needs into operational processes and system rules.

• Experience in coordinating system configurations, change controls, testing, audits, and cross-functional process enhancements.

• Strong analytical, communication, and problem-solving abilities.

• Knowledge of DMEPOS or medical supply reimbursement is preferred.

• Familiarity with Brightree, InRule, or similar rules engines; understanding of Medicare, Medicaid, Medicare Advantage, and commercial payer requirements; experience with EDI and clearinghouse processes is preferred.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off plan.

• Health savings account (HSA).

• 401k savings plan.

• Access to wages before payday with myFlexPay.

• Flexible spending accounts (FSAs).

• Short- and long-term disability coverage.

• Work-Life resources.

• Paid parental leave.

• Healthy lifestyle programs.

• Bonus eligibility.