Director, Payer Operations

Carle Health•Champaign, IL

4d•$54 - $93•Onsite

About The Position

The Director, Payer Operations will satisfy commitments made to Internal Audit following January 2026 audit results improve operational readiness, implement execution of payer contract terms, monitor payer performance, monthly management and submission of provider enrollments, and provider roster management.

Requirements

Bachelor's Degree: Finance, Economics, Operations Management, or related
Related field - 10 years (Healthcare Finance or Accounting)
Strong analytical, problem-solving and leadership skills.
Excellent track record of achieving operational and process excellence and high efficiency.
Demonstrated ability to work independently as well as collaborate among various teams within Carle.
Demonstrated ability to develop and manage team members effectively as well as other areas within Carle that are impacted by payer contracts and provider enrollment processes.

Responsibilities

Operationalize contract terms and payer agreements
Ensure claims pay correctly, authorizations function efficiently, contract terms are executable, and payer issues are escalated and resolved quickly.
Develop, implement, and maintain specific contract monitoring policy including escalation processes and specify parameters to guide team members when addressing inadequate payer performance and disputes.
Coordinate with internal Carle Health teams on payer contracts and requirements, denials and claims payment issues, Payer Platform/data integration, interoperability, and transparency requirements.
Oversee provider roster management
Manage enrollment processes for new and existing providers for non-governmental payers and commercial payer roster updates.
Prepare and maintain monthly rosters and submissions to commercial payers, including establishing and maintaining written procedures.
Develop, implement, and optimize workflows, processes, and procedures for Prior Authorization/Utilization Management coordination, coordinate with case management and patient access, partner with appropriate teams on Epic optimization.
Coordinate root-cause investigations and manage implementation of solutions.
Minimize revenue leakage through operational excellence.
Support Facility Credentialing and related location changes, including partnering with staff and legal teams on notification of Carle location changes and other changes required for appropriate reimbursement related to federal programs.