Director, Payer Operations

Carle Health•Champaign, IL

3d•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. This role is crucial for ensuring the efficient and effective execution of payer contracts, optimizing revenue, and maintaining accurate provider information.

Requirements

Finance, Economics, Operations Management, or related field - 10 years (Healthcare Finance or Accounting) Work Experience
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 to ensure claims pay correctly, authorizations function efficiently, contract terms are executable, and payer issues are escalated and resolved quickly.
Develop, implement, and maintain a specific contract monitoring policy, including escalation processes and parameters for 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, including managing 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, 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, and partner with appropriate teams on Epic optimization.
Coordinate root-cause investigations and manage the implementation of solutions.
Minimize revenue leakage through operational excellence.
Support Facility Credentialing and related location changes, partnering with staff and legal teams on notification of Carle location changes and other changes required for appropriate reimbursement related to federal programs.