Payer Implementation Lead (Consultant position)

World Class Health; United States; Remote; USD 180,000 - 240,000; Full time

Job summary

World Class Health seeks a Senior Payer Implementation Consultant to lead multi-client launches across national BUCA carriers, regional health plans, and TPAs. You will translate employer benefit designs into payer operations and own the go-live deliverables.

As the senior expert, you will design hard and soft mandates, manage prior authorization and claims feeds, and coordinate with clinical, data, and compliance teams to ensure on-time production launches.

Qualifications

• Experience implementing Centers of Excellence, specialty-care, navigation in commercial ASO/self-funded plans.
• Experience implementing hard mandates, carve-outs, steerage, navigation.
• Strong knowledge of prior authorization workflows, PA-triggered programs, claims and eligibility data, accumulators, appeals, denials, exemptions.
• Experience with national carriers and/or TPAs; BUCA implementation is preferred.
• Senior operator who can work independently and drive execution.

Responsibilities

• Lead implementation of hard mandates/carve-outs with benefits configuration, member redirection, exceptions, escalations and workflows with carriers and TPAs.
• Implement soft mandates and required information sessions triggered by prior authorization activity.
• Establish appeals, denial, exception, and member escalation processes.
• Own implementation of required prior authorization and claims feeds, including specs, testing, issue resolution and production deployment.
• Coordinate with payer implementation, clinical/UM, data/EDI, and operations teams to resolve barriers and keep integrations on schedule.
• Serve as senior payer implementation expert across multiple concurrent client launches.
• Translate client requirements into payer workplans, identify stakeholders in complex payer orgs, drive go-live decisions.
• Coordinate with WCH implementation, clinical, product/data, and client teams while owning payer deliverables through production launch.
• Report to the Chief Medical Officer and collaborate across clinical operations, sales, data, and compliance teams.

Skills

Centers of Excellence

Hard mandates

Prior authorization

Data feeds

BUCA implementation

Independent execution

Job description

Company background

World Class Health was built to solve one of healthcare’s most expensive and overlooked problems: when employees face high-stakes medical decisions, they often lack access to trusted, high-quality care at an affordable cost.

Traditional healthcare systems force patients to navigate rising costs, fragmented care, limited

visibility into provider quality, and unclear out-of-pocket exposure, often during the most vulnerable moments of their lives. WCH exists to change that. Through our medically led Global Centers of Excellence platform, AI-driven insights, transparent provider relationships, and concierge care navigation, we connect patients to top 1% care globally while helping employers reduce healthcare costs and improve outcomes.

WCH focuses on high-cost specialty care episodes including orthopedics, spine, cardiac care,

oncology, imaging, infusion, and complex surgical needs. Our model combines predictive analytics, proactive outreach, nurse-led care management, direct provider contracting, and transparent bundled pricing to help employers lower costs while improving the patient experience.

Our Vision

World Class Health’s vision is the compass that guides every strategic decision we make as we grow, scale, and serve more patients around the world. To create a world where everyone can access the best possible care, regardless of where they live or their circumstances.

Our Mission

To empower employees and their families to overcome geographic, financial, and informational barriers to accessing top 1% care all around the world.

Role: Payer Implementation Lead (Consultant) Role

Role Description

Senior, hands-on payer implementation consultant supporting up to eight upcoming World Class

Health self-insured client launches across national BUCA carriers, regional health plans, and TPAs. The role owns the execution required to translate employer benefit design and contracted

requirements into functioning payer operations.

Core Mandate

Implement hard and soft mandate designs

• Lead implementation of hard mandates/carve-outs, including benefit configuration, member redirection, exceptions, escalations, and operational workflows with carriers and TPAs.
• Implement soft mandates, including required informational or navigation sessions triggered by prior authorization activity.
• Establish appeals, denial, exception, and member escalation processes so programs function reliably in production.

Establish payer data integrations

• Own implementation of required prior authorization and claims feeds, including specifications, testing, issue resolution, and production deployment.
• As required by individual clients, support related eligibility, accumulator, and other payer data exchanges.
• Work directly with payer implementation, clinical/UM, data/EDI, and operations teams to resolve barriers and keep integrations on schedule.

Drive implementations to completion

• Serve as the senior payer implementation expert across multiple concurrent client launches.
• Translate client requirements into detailed payer workplans, identify the right stakeholders within complex payer organizations, and drive decisions through go-live.
• Coordinate closely with WCH implementation, clinical, product/data, and client teams while personally owning payer deliverables through successful production launch.

Reporting & Collaboration

• The consultant will report to the Chief Medical Officer and work cross-functionally across World Class Health, with close collaboration across clinical operations, sales, data, and legal/compliance teams.

Required experience

Qualifications

• Direct experience implementing Centers of Excellence, specialty-care, navigation, or healthcare point-solution programs within commercial ASO/self-funded plans.
• Experience implementing hard mandates, carve-outs, steerage, required navigation, or comparable benefit-design mechanisms.
• Strong working knowledge of prior authorization workflows, PA-triggered programs, claims and eligibility data, accumulator feeds, appeals, denials, and exceptions.
• Experience working with national carriers and/or TPAs; BUCA implementation experience is strongly preferred.
• Senior operator who can work independently and drive execution—not simply manage payer relationships.

Engagement Structure

• This is a project-based consulting engagement, not an hourly or retainer arrangement.
• Compensation will be tied to clearly defined, successfully completed projects.

• Examples of project completion include:
• Successful implementation and operationalization of a client hard or soft mandate with the applicable payer/TPA.
• Successful implementation of a contracted PA, claims, or other required data feed through production.
• Completion of associated routing, exception, appeals, and operational workflows required for launch.

Initial scope will support payer work across up to 8 upcoming client implementations, with additional projects possible as the business scales.

Why Join Us

World Class Health and World Class Fertility are uniquely positioned to define the future of specialty healthcare, with WCH transforming how employees access complex specialty care and WCF extending that model to family building, one of the most expensive and fragmented healthcare journeys in America. The World Class ecosystem has a differentiated model that combines global access to top quality care, medically led navigation, AI-driven insights, and aligned economic incentives through transparent, cost-reducing pricing.

This creates a rare opportunity to join a company with both meaningful market whitespace and proven early traction, and to help shape a category-defining brand from day one.

As part of the World Class ecosystem, you will help build a category-defining business alongside exceptional leaders who operate with urgency, high ownership, and uncompromising standards. The work is demanding, the pace is intense, and the opportunity to create outsized impact - for patients, employers, and the broader healthcare ecosystem - is extraordinary. For leaders motivated by solving hard problems and building something that meaningfully changes lives, WCH offers the opportunity to do the most consequential work of their career.