Payer Rules & RCM Optimization Manager

Cardinal Health; Lansing (MI); Remote; USD 89.000 - 114.000; Vollzeit

Benefits dieser Stelle

Medical, dental and vision coverage

401k savings plan

Paid time off

Zusammenfassung

Cardinal Health seeks a Manager, Payer Rules & Revenue Cycle Optimization to lead a team of three FTEs in implementing and maintaining payer rules across the revenue cycle. You will translate contracts into system rules, oversee Brightree and InRule configurations, and partner with IT and vendors to ensure accurate, timely payer processes.

The role drives denials reduction, faster collections, and standardized controls, with governance for change management and policy updates across the

Qualifikationen

• Bachelor's degree in healthcare administration, business, finance, information systems, or related field.
• 5+ years in healthcare revenue cycle, payer operations, reimbursement, billing systems, or payer rules preferred.
• Demonstrated leadership or supervision of staff.
• Strong knowledge of payer contracts, billing requirements, claims processing, denial management, and translating business needs into operational processes and system rules.
• Experience coordinating system configurations, change controls, testing, audits, and cross-functional process improvement; strong analytical, communication, and problem-solving skills.
• Brightree, InRule, or comparable rules engines; Medicare, Medicaid, Medicare Advantage and commercial payer requirements; EDI and clearinghouse processes preferred.

Aufgaben

• Lead, coach, and manage a team of three FTEs; establish priorities, allocate work, monitor quality and productivity, develop team capabilities, and ensure timely completion of payer rule and contract implementation requests.
• Oversee end-to-end operational readiness for new payer contracts, renewals, amendments, and updates to existing agreements, confirming payer requirements are configured, tested, communicated, and ready by applicable effective dates.
• Translate payer contracts, reimbursement policies, and billing guidelines into actionable system rules, business requirements, standard operating procedures, and controls across front-end, mid-cycle, and back-end RCM.
• Own functional accuracy and ongoing maintenance of payer-specific configurations within Brightree and InRule, including coverage and HCPCS requirements, modifiers, eligibility, authorization, documentation, medical necessity, frequency limits, and claim submission edits.
• Partner with IT, system administrators, vendors, and clearinghouses to develop specifications, oversee configuration changes, coordinate user acceptance testing, validate results, and resolve conflicting or ineffective Brightree, InRule, or clearinghouse rules.
• Create a structured governance process for intake, prioritization, approval, documentation, auditing, and ongoing validation of payer rule changes, including ownership, effective dates, change logs, and implementation status.
• Proactively monitor Medicare, Medicaid, Medicare Advantage, commercial payer, and manufacturer policy updates; assess impact and communicate requirements to Payer Relations, Customer Operations, Sales, Order Processing, and RCM teams.
• Partner with Payer Relations and Market Access to clarify contract provisions and investigate differences between contracted requirements, system configuration, and actual payer adjudication or reimbursement.
• Analyze payer denials, clearinghouse rejections, unbilled claims, underpayments, and reimbursement variances to identify systemic configuration or process gaps; prioritize remediation by financial and operational impact.
• Implement upstream, automated controls and payer-specific pre-bill edits to reduce manual work, avoidable denials, revenue leakage, and delayed cash collections.
• Coordinate cross-functional readiness, testing, training, and communication for payer rule changes; elevate risks and ensure accountable owners close identified gaps.
• Support Brightree transformation, integrations, and enterprise standardization efforts while accommodating legitimate payer, product, and business-specific requirements.
• Develop actionable metrics and report progress on contract implementation timeliness, configuration accuracy, rule-related denial trends, change request backlog, and measurable revenue cycle improvements.
• Direct oversight of policies and procedures execution
• Ensure Payer Rules FTEs operate within guidelines and remain compliant

Kenntnisse

Leadership

Healthcare revenue cycle

Analytical thinking

Communication

Problem solving

Ausbildung

Bachelor's degree in Healthcare Administration / Business / Finance / Information Systems

Tools

Brightree

InRule

Jobbeschreibung

Cardinal Health seeks a Manager, Payer Rules & Revenue Cycle Optimization to lead a team of three FTEs in implementing and maintaining payer rules across the revenue cycle. You will translate contracts into system rules, oversee Brightree and InRule configurations, and partner with IT and vendors to ensure accurate, timely payer processes.

The role drives denials reduction, faster collections, and standardized controls, with governance for change management and policy updates across the