Payor Relations & Clinical Criteria Manager

SOLVENTUM • San Antonio, TX

5d • Hybrid

About The Position

Payor Relations & Clinical Criteria Manager, Revenue Cycle Management | Solventum 3M Health Care is now Solventum At Solventum, we enable better, smarter, safer healthcare to improve lives. As a new company with a long legacy of creating breakthrough solutions for our customers’ toughest challenges, we pioneer game-changing innovations at the intersection of health, material and data science that change patients' lives for the better while enabling healthcare professionals to perform at their best. Because people, and their wellbeing, are at the heart of every scientific advancement we pursue. We partner closely with the brightest minds in healthcare to ensure that every solution we create melds the latest technology with compassion and empathy. Because at Solventum, we never stop solving for you. The Impact You’ll Make in this Role As a Payor Relations & Clinical Criteria Manager, you will have the opportunity to tap into your curiosity and collaborate with some of the most innovative and diverse people around the world. Here, you will make an impact by: Leading, developing, and mentoring a team responsible for monitoring, analyzing, and interpreting healthcare coverage criteria changes across Medicare, Medicaid, and Commercial payors. Defining and governing payor criteria and billing rules aligned to payor manuals, contracts, and payor behavior to support operational accuracy and future-state decision support capabilities. Developing and maintaining master data structures for payor billing rules, clinical coverage criteria, and medical necessity requirements to support consistent execution across the revenue cycle. Communicating and educating Homecare Operations and Billing & Collections teams on evolving coverage requirements, documentation expectations, and payor-specific billing rules. Driving revenue cycle performance by strengthening payor-related processes, resolving AR issues tied to payor system/process defects, and partnering cross-functionally with Managed Care Contracts, MCO Sales, Contracting, Operations, and Billing teams.

Requirements

• Bachelor’s degree or higher (completed and verified prior to start) from an accredited institution AND seven (7) years of experience in healthcare revenue cycle, payor policy, managed care, and/or billing criteria OR High School Diploma/GED (completed and verified prior to start) from an accredited institution AND eleven (11) years of experience in healthcare revenue cycle, payor policy, managed care, and/or billing criteria AND
• Five (5) years of people leadership experience in revenue cycle, clinical documentation, and/or payor relations.
• Strong working knowledge of Medicare, Medicaid, and Commercial coverage criteria.
• Strong contract analysis and interpretation skills.
• Proven ability to analyze complex regulatory and coverage policy changes and translate them into operational guidance.
• Excellent communication skills with demonstrated ability to educate clinical, billing, and operational partners effectively.
• Must be legally authorized to work in country of employment without sponsorship for employment visa status (e.g., H1B status).

Nice To Haves

• Experience in Homecare, DME, or post-acute care reimbursement.
• Lean, Six Sigma, or structured problem-solving training.
• Strong ability to influence without authority across large, matrixed organizations.

Responsibilities

• Leading, developing, and mentoring a team responsible for monitoring, analyzing, and interpreting healthcare coverage criteria changes across Medicare, Medicaid, and Commercial payors.
• Defining and governing payor criteria and billing rules aligned to payor manuals, contracts, and payor behavior to support operational accuracy and future-state decision support capabilities.
• Developing and maintaining master data structures for payor billing rules, clinical coverage criteria, and medical necessity requirements to support consistent execution across the revenue cycle.
• Communicating and educating Homecare Operations and Billing & Collections teams on evolving coverage requirements, documentation expectations, and payor-specific billing rules.
• Driving revenue cycle performance by strengthening payor-related processes, resolving AR issues tied to payor system/process defects, and partnering cross-functionally with Managed Care Contracts, MCO Sales, Contracting, Operations, and Billing teams.

Benefits

• Solventum offers many programs to help you live your best life – both physically and financially.
• To ensure competitive pay and benefits, Solventum regularly benchmarks with other companies that are comparable in size and scope.
• Medical, Dental & Vision, Health Savings Accounts, Health Care & Dependent Care Flexible Spending Accounts, Disability Benefits, Life Insurance, Voluntary Benefits, Paid Absences and Retirement Benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Manager