Manager, Payer Rules & Revenue Cycle Optimization

What Revenue Cycle Management (RCM) contributes to Cardinal Health
Practice Operations Management oversees the business and administrative operations of a medical practice.

Revenue Cycle Management (RCM) is responsible for managing the financial lifecycle of patient accounts and ensuring timely and accurate payment for services provided. This job family is focused on a series of clinical and administrative processes that healthcare providers utilize to capture, bill, and collect patient service revenue in a manner that is compliant with payer rules and requirements. The revenue cycle shadows the entire patient care journey and begins with patient intake and ends when the patient’s account balance is zero. This team also encompasses a payer administration function that ensures we are successfully operationalizing payer rules and requirements as well as facilitating payer relations and escalation efforts.

Position Summary

The Manager, Payer Rules & Revenue Cycle Optimization leads the operational implementation and ongoing maintenance of payer rules and contractual requirements across the revenue cycle. The role oversees a team of three FTEs responsible for payer rule administration and related operational support, ensuring new and existing payer agreements, amendments, and policy changes are accurately translated into workflows, system configuration, and preventive controls. The Manager provides functional oversight of Brightree and InRule payer rules, partnering with Payer Relations, Market Access, RCM Operations, IT, and Business Transformation to improve billing accuracy, prevent avoidable denials, accelerate collections, and support consistent execution across businesses.

Responsibilities

• 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; escalate 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

Qualifications

• Bachelor's degree in healthcare administration, Business, Finance, Information Systems, or related field, or equivalent relevant experience preferred.
• 5+ years of experience in healthcare revenue cycle, payer operations, reimbursement, billing systems, or payer rules preferred.
• Demonstrated leadership or supervision of staff.

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