Job Title: Sr. Director, Payer Operations | Position Type: Full Time |
Work Setting: In Office | Department: Core Ops – Payer Ops |
Reports to: Head of Payments | FLSA: Salary, Exempt |
|
ABOUT VAXCARE |
The healthcare system is complex, presenting challenges for everyone—patients, doctors, nurses, office managers, and billers alike. At VaxCare, we aim to streamline this complexity, eliminating unnecessary costs and confusion so that practices can focus on their important work: caring for patients. Our innovative solutions include a vaccine management and LARC access platform trusted by over 20,000 active providers nationwide. This service is powered by a multidisciplinary team of dedicated professionals who lead with integrity and a relentless drive to exceed expectations, bringing clarity and efficiency to the often-overwhelming world of healthcare. |
|
THE POSITION |
| The Sr. Director of Payer Operations will build and lead the function that converts executed payer contracts into operational readiness. This leader will establish the operating model, capabilities, processes, controls and governance required to scale contract abstraction, credentialing and enrollment, contract and fee-schedule configuration, payer requirements management, go-live readiness and operational remediation. Reporting to the Head of Payments, this role serves as the link among Market Access, RCM, Product, Technology, Finance, Legal and provider-facing operations, ensuring contractual terms are accurately translated into systems, workflows and reimbursement logic and recurring reimbursement risks are corrected at their source. |
|
ESSENTIAL RESPONSIBILITIES |
| Contract Intake and Operationalization - Own the operational handoff of executed payer contracts, amendments, reimbursement changes and payer requirements after commercial negotiation is complete.
- Maintain an authoritative repository of contracts, amendments, fee schedules and effective dates, with operational terms consistently abstracted and searchable.
- Translate payer requirements and policy changes into implementation plans with clear owners, milestones, dependencies, testing and go-live criteria.
- Provide implementation input during contract discussions and quickly identify and resolve post-contract implementation defects.
Credentialing, Enrollment, and Provider Maintenance - Own provider and group enrollment, re-enrollment, recredentialing, CAQH and payer roster maintenance.
- Establish visible tracking of enrollment status, defects, dependencies, effective dates and readiness risks, resolving issues before they create avoidable reimbursement impacts.
- Confirm enrollment, network participation and roster readiness for new practice partners before inventory is placed or claims are submitted.
Billing Setup and Contract Configuration - Translate payer-specific contractual terms, billing policies, reimbursement requirements and claims rules into clear operational requirements and standards.
- Own fee-schedule loading, billing-rule configuration, reimbursement logic, payer identifiers, provider configuration and related setup.
- Establish testing, validation, change-control and signoff processes for new configurations and material changes.
- Partner with Product and Technology to improve configuration capabilities and reduce manual complexity.
- Own recurring reimbursement updates, including Medicare Part B vaccine payment changes and contractual rate escalators.
Operational Payer Issue Resolution - Own resolution of operational defects involving enrollment, rosters, contract setup, fee schedules, configuration, provider data, eligibility routing and implementation.
- Partner with RCM to identify and remediate upstream defects driving claim or payment issues and confirm subsequent claims adjudicate as expected.
- Escalate to Market Access when resolution requires contract interpretation or change, payer policy intervention or executive payer engagement.
- Participate in joint operating committees (JOCs) and recurring operational meetings with key payers alongside Market Access.
Payment Integrity and Reimbursement Assurance - Establish monitoring with RCM and Analytics to identify systemic reimbursement variances and implementation defects and determine root cause.
- Lead corrective action for issues caused by enrollment, setup, configuration or payer operational defects.
- Partner with RCM to quantify financial impact and recovery opportunities, while RCM retains accountability for claim recovery and cash collection.
- Implement controls to prevent recurrence and report actual versus expected contract performance to Market Access to inform negotiations.
Payer Audit Intake and Management - Establish a centralized process for payer audit intake and management, with clear handoffs and decision rights across Market Access, Payer Operations and RCM.
- Maintain visibility to audit status, ownership and next steps, with RCM responsible for claim-level record production and recoupment or repayment activity.
Cross-Functional Governance and Payer Dashboard - Establish recurring governance for implementation status, readiness risks, operational issues, root-cause remediation and recurrence prevention.
- Co-develop and own a shared payer dashboard with Market Access and RCM covering key operational, reimbursement and RCM KPIs, and lead recurring cross-functional payer reviews.
- Establish clear decision rights and accountability for common payer issues and scenarios.
Measures of Success - Timely and accurate implementation of payer contracts, changes, new products and seasonal requirements.
- Accurate enrollment, rosters, fee schedules, billing rules and payer configurations.
- Reduced denials and reimbursement leakage attributable to upstream operational defects.
- Faster issue resolution, lower recurrence and greater visibility and accountability for payer performance.
- A well-designed organization with skilled, highly engaged talent.
Leadership Expectations - Model VaxCare’s values and build a high-performing Payer Operations organization with strong operating disciplines, controls, documentation, governance and performance measures.
- Create clear accountability across contracting, implementation and claim-recovery handoffs, fostering a culture of accuracy, urgency, transparency, resilience and continuous improvement.
- Use data to identify root causes, quantify financial and operational impact and prioritize high-value upstream improvements.
|
|
REQUIRED EXPERIENCE & QUALIFICATIONS |
- 10+ years in payer operations, managed-care operations, provider contracting operations, credentialing/enrollment, reimbursement operations, revenue cycle or a related healthcare field.
- Demonstrated success building or materially transforming a payer operations or related function in a complex, rapidly evolving environment.
- Deep knowledge of commercial and government payer requirements, enrollment, claims, reimbursement, rosters, fee schedules, configuration, readiness testing and issue management.
- Experience translating contracts into operational requirements across enrollment, configuration, billing and reimbursement; payer-side experience in provider data, network management or claims configuration strongly preferred.
- Experience in high-volume, multi-site environments such as pharmacy, laboratory, DME or vaccines, including medical and pharmacy benefit billing such as Medicare Parts B and D.
- Strong analytical, executive communication, cross-functional leadership and team-building capabilities.
- Located in Central Florida with occasional travel (<10%).
|
|
COMPETENCIES: Core to all positions at VaxCare |
We Live (and Work) by Our Values: |
| - Building a team culture founded on trust, collaboration, and delivery excellence - Belief in Something Bigger than Ourselves – Capacity to derive meaning from a larger purpose - Humility as a Posture of Learning – Burning curiosity to learn without ego - Adaptability & Embracing Change – Nimbleness & ready to seize new opportunities |
Additional “Must Haves”: |
| - Dependability – Must be able to meet deadlines, work independently, maintain focus, & punctual - Interpersonal Skills – Builds strong relationships & contributes to a positive work environment. - Computer Skills – Skilled with computers, learns new tools quickly. - Ethics – Honest, accountable, maintains confidentiality. |
|
OTHER RESPONSIBILITIES |
- Commute to Office: Must be able to commute to and from the corporate office for each scheduled shift.
- Prolonged sitting or standing: Team members must be able to remain in a stationary position for extended periods, as much of the work involves sitting at a computer or workstation. Some hybrid or office-based roles may also require the ability to stand for portions of a shift.
- Repetitive motions: Significant use of the hands, wrists, and fingers is required for tasks like typing, using a computer mouse, and handling paperwork.
- Visual acuity: This job requires the ability to view a computer screen and read documents for extended periods.
- Communication: Team members must be able to clearly express and exchange ideas in English to effectively communicate with customers and co-workers.
- Occasional lifting: Many office-based jobs specify the ability to occasionally lift or move up to 10-20 pounds to handle supplies or equipment.
|
| Physical Requirements/Work Environment: | TASK | Continuous | Intermittent | Seldom | N/A | Regular & Reliable Attendance | X | | | | Standing/Walking | X | | | | Travel/Driving/Operating Vehicle | | | | X | Sitting (desk/computer work) | X | | | | Lifting/Lowering/Carrying (up to 20lbs) | | | X | | Reaching/Bending/Twisting | | | X | | Hand/Wrist Use (typing/mouse/writing) | X | | | | In person attendance for meetings/conferences | X | | | | Operating Mobile Equipment/Machinery | | | | X | | |
