[Hiring] Manager, Payer Rules & Revenue Cycle Optimization @Cardinal Health

Role Description

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.

• 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.
• Strong knowledge of payer contractual and 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.
• DMEPOS or medical supply reimbursement preferred.
• Brightree, InRule, or comparable rules engines; Medicare, Medicaid, Medicare Advantage and commercial payer requirements; EDI and clearinghouse processes preferred.

Requirements

• Manages department operations and supervises professional employees, front line supervisors and/or business support staff.
• Participates in the development of policies and procedures to achieve specific goals.
• Ensures employees operate within guidelines.
• Decisions have a short term impact on work processes, outcomes and customers.
• Interacts with subordinates, peers, customers, and suppliers at various management levels; may interact with senior management.
• Interactions normally involve resolution of issues related to operations and/or projects.
• Gains consensus from various parties involved.

Benefits

• Medical, dental and vision coverage.
• Paid time off plan.
• Health savings account (HSA).
• 401k savings plan.
• Access to wages before pay day with myFlexPay.
• Flexible spending accounts (FSAs).
• Short- and long-term disability coverage.
• Work-Life resources.
• Paid parental leave.
• Healthy lifestyle programs.