Payor Relations, Clinical Criteria Manager
Solventum
full-time
Posted on:
Location Type: Hybrid
Location: San Antonio • Texas • United States
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Salary
💰 $143,200 - $196,900 per year
About the role
- 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 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 from an accredited institution and eleven (11) years of experience in healthcare revenue cycle, payor policy, managed care, and/or billing criteria
- 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.
Benefits
- Medical
- Dental & Vision
- Health Savings Accounts
- Health Care & Dependent Care Flexible Spending Accounts
- Disability Benefits
- Life Insurance
- Voluntary Benefits
- Paid Absences
- Retirement Benefits
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
healthcare revenue cyclepayor policybilling criteriacontract analysisregulatory analysisdata structure developmentmedical necessity requirementsclinical documentationpayor billing rulesAR issue resolution
Soft Skills
leadershipmentoringcommunicationeducationcross-functional collaborationanalytical skillsoperational guidanceproblem-solvinginterpersonal skillsteam development
Certifications
Bachelor’s degreeHigh School Diploma/GED