Payer Operations Specialist

Position Summary

The Payer Operations Analyst plays a critical role in ensuring the accuracy, efficiency, and integrity of payer-related setup and operations across Thriveworks systems. This provider-side position is responsible for translating payer contracts into precise system configurations, managing fee schedules, maintaining high-quality payer data, and supporting operational readiness across Revenue Cycle, Credentialing, and EHR functions.

The ideal candidate is detail-oriented, proactive, and highly skilled in payer configuration workflows, EHR setup, system QA, and payer portal navigation. This role includes regular collaboration with internal partners and a third‑party billing vendor to ensure flawless 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 the EHR and related systems. Support the loading, updating, and auditing of payer fee schedules based on executed contracts, amendments, or updates from payer portals (e.g., Availity, NaviNet, Change Healthcare). Establish and enforce standardized naming conventions for payers, networks, and plans across scheduling tools and EHR systems. Quality Assurance & Data Integrity

Partner with the EHR administration team to configure and test payer setups to ensure proper routing for 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 and communications for updates to policies, fee schedules, and billing guidelines; ensure timely implementation of required changes. Conduct outreach to selected payer partners for rate reviews, fee schedule requests, or policy clarifications. Cross-Functional Collaboration

Partner with RCM, Credentialing, Finance, Compliance, and operational teams to ensure seamless handoff 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, improve data hygiene, enhance efficiency, and streamline documentation. Lead or contribute to special projects focused on improving operational infrastructure and payer-related workflows. Qualifications

Required

Bachelor’s degree in Healthcare Administration, Business, or related field; or equivalent experience. 3–5 years of experience in healthcare payer operations, provider network setup, EHR configuration, or related areas within a provider organization. Strong understanding of payer configuration elements: payer IDs, EDI enrollments, claims addresses, plan IDs, reimbursement structures, and fee schedule loading. Experience collaborating with third‑party billing vendors or RCM teams. Proficiency with payer portals such as Availity, NaviNet, and Change Healthcare. Demonstrated attention to detail with proven success in maintaining data integrity and QA processes. Strong organizational, communication, and project management skills. Preferred

Experience in behavioral health or outpatient healthcare settings. Familiarity with AdvancedMD or similar EHR/Practice Management systems. Knowledge of payer policies, reimbursement methodologies, and provider enrollment workflows.

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