Director, Payer Operations

Overview

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.

Qualifications

N/A Education: Experience In Lieu of Education or Bachelor's Degree: Finance, Economics, Operations Management, or related Work Experience: Related field - 10 years (Healthcare Finance or Accounting) Specialized Knowledge & Skills 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.

About Us

Find it here. Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College.

Carle Bro. Menn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.

| For more information: human.resources@carle.com.

Compensation

and Benefits The compensation range for this position is $54.28per hour - $93.36per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model.

Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits. 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.

Certifications: N/A Education: Experience In Lieu of Education or Bachelor's Degree: Finance, Economics, Operations Management, or related Work Experience: Related field - 10 years (Healthcare Finance or Accounting) Specialized Knowledge & Skills 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.