Hybrid Payor Relations, Clinical Criteria Manager

at Solventum

• Job title: Payor Relations, Clinical Criteria Manager
• Job type: Full Time
• Experience level: Senior, Lead
• Salary: $143,200 - $196,900 per year
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, San Antonio, United States

About the role

• Payor Relations & Clinical Criteria Manager overseeing healthcare coverage criteria and leading a team. Focusing on Medicare, Medicaid, and Commercial payors' billing rules and operational accuracy.

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.

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