Manager, Payor Contract Integrity & Delegation Operations

Advanced Medical Management, Inc.; Long Beach (CA); On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Employer-paid HMO

Discounted dental and vision premiums

401(k) plan

Generous PTO

Tuition reimbursement

Job summary

A leading healthcare firm in California is seeking a highly analytical Manager, Payor Contract Integrity & Delegation Operations. This role ensures capitation payments and claims-based reimbursements are aligned with contracted terms. Responsibilities include managing discrepancies, validating system configurations, and coordinating with cross-functional teams. Ideal candidates should have significant experience in healthcare economics and strong project management abilities. Join us for a comprehensive benefits package that prioritizes your well-being and career growth.

Qualifications

• 5+ years of experience in payor contracting operations, healthcare economics, capitation reconciliation, delegated risk operations, or MSO finance.
• Strong working knowledge of capitated payment structures, risk-bearing provider contracts, and DOFR frameworks.
• Demonstrated experience managing cross-functional implementation projects.

Responsibilities

• Serve as primary liaison with payors to identify and resolve capitation discrepancies.
• Partner with Healthcare Economics and Finance to reconcile capitation models.
• Analyze payment variances and validate alignment to contracted rates.
• Support audit readiness related to delegated and capitated arrangements.

Skills

Analytical skills

Financial analysis

Project management

Excel proficiency

Education

Bachelor’s degree

Advanced degree

Job description

Seoul Medical Group (SMG) is seeking a highly analytical and detail-oriented Manager, Payor Contract Integrity & Delegation Operations to serve as the operational bridge between payors, contracting, healthcare economics, finance, and MSO teams. This role is responsible for ensuring that capitation payments and claims-based reimbursements are accurate and aligned with contracted terms, and that delegated, capitated risk contracts are implemented correctly within MSO systems and Delegated Configuration, including DOFR alignment. The individual will not perform system configuration directly but will project manage implementation, validate alignment to contract terms, and coordinate cross-functional communication to ensure financial and operational accuracy.

Key Responsibilities

• Serve as primary liaison with payors to identify and resolve capitation discrepancies, claims underpayments, and overpayments.
• Partner with Healthcare Economics and Finance to reconcile capitation models against actual payment files.
• Analyze payment variances and validate alignment to contracted rates, attribution models, and DOFR terms.
• Escalate discrepancies to payors and manage issue resolution through completion.
• Translate contract language (risk terms, DOFR allocations, carve-outs, fee schedules) into implementation requirements.
• Partner with Payor Contracting to ensure newly executed contracts are accurately operationalized.
• Coordinate with the AMM MSO team and Delegated Configuration teams to ensure capitated contracts are configured properly.
• Project manage contract implementation timelines and ensure cross-functional alignment.
• Validate system configuration reflects negotiated contract terms prior to go-live.
• Develop structured processes for post-implementation validation of capitated and delegated contracts.
• Identify financial risk exposure due to misconfiguration or payment inaccuracies.
• Support audit readiness related to delegated and capitated arrangements.

Qualifications

• Bachelor’s degree required; advanced degree preferred.
• 5+ years of experience in payor contracting operations, healthcare economics, capitation reconciliation, delegated risk operations, or MSO finance.
• Strong working knowledge of capitated payment structures, risk-bearing provider contracts, and DOFR frameworks.
• Demonstrated experience managing cross-functional implementation projects.
• Strong Excel and financial analysis skills.

Preferred Qualifications

• Experience within an IPA, MSO, health plan, or delegated risk organization.
• Familiarity with delegated configuration systems and contract loading workflows.
• Exposure to Medicare Advantage financial models, Stars, or risk adjustment.
• Experience resolving payment disputes with payors.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.