Payer Implementation Lead — Senior Consultant

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

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.