About the job
Position Overview
The Payer Operations Specialist is pivotal in ensuring the precision, efficiency, and integrity of payer-related setups and operations across Thriveworks systems. This role involves translating payer contracts into accurate system configurations, managing fee schedules, upholding high-quality payer data, and supporting operational readiness across Revenue Cycle, Credentialing, and EHR functions.
The ideal candidate will be detail-oriented, proactive, and possess advanced skills in payer configuration workflows, EHR setup, system quality assurance, and payer portal navigation. The role includes regular collaboration with internal teams and a third-party billing vendor to ensure exceptional execution of payer operations.
Key Responsibilities
- Payer Configuration & System Management: Implement and maintain payer configuration details (payer IDs, claims routing, EDI enrollment details, billing requirements, plan IDs, etc.) across EHR and related systems. Provide support in loading, updating, and auditing payer fee schedules based on executed contracts and updates from payer portals (e.g., Availity, NaviNet, Change Healthcare). Establish and enforce standardized naming conventions for payers, networks, and plans.
- Quality Assurance & Data Integrity: Partner with the EHR administration team to configure and test payer setups for proper routing related to eligibility, claims, and remittance data. Conduct ongoing QA audits to validate payer configuration accuracy and maintain high-quality system data. Maintain a centralized repository of payer information, including configurations, fee schedules, contact lists, portal credentials, and audit logs.
- Vendor & Payer Coordination: Collaborate closely with a third-party billing vendor to share configuration updates, resolve claim routing issues, and ensure alignment on QA routines and operational processes. Monitor payer portals for updates to policies, fee schedules, and billing guidelines; ensure timely implementation of changes. Conduct outreach to selected payer partners for rate reviews and policy clarifications.
- Cross-Functional Collaboration: Work alongside RCM, Credentialing, Finance, Compliance, and operational teams to ensure a seamless transition from contract execution to operational readiness. Support internal and external audits by providing accurate and current configuration documentation.
- Continuous Improvement: Identify opportunities to automate payer setup processes, enhance data hygiene, improve efficiency, and streamline documentation. Lead or contribute to special projects aimed at improving operational infrastructure and payer-related workflows.