Manager, Revenue Integrity&Formulary Strategy

About the role

You will serve as a revenue integrity and compliance subject matter expert (SME), responsible for ensuring XiFin customer formularies, drug lists, and utilization management criteria are designed, implemented, and maintained to support accurate charge capture, compliant billing, and defensible reimbursement. You will manage a small team, overseeing day-to-day priorities, development, and performance while ensuring consistent execution of revenue integrity operations and delivery against key outcomes.

Responsibilities

• Oversee XiFin formulary data, including maintenance and updates within the Centralized Formulary System, ensuring clean claim submission, revenue cycle integrity, compliance, and audit readiness
• Ensure formulary-driven billing logic, drug identifiers, and utilization management criteria align with payer policies, industry coding standards (HCPCS, CPT, NDC), and regulatory guidance (CMS, OIG)
• Serve as a subject matter expert in Medicare Part B coding, billing, and coverage requirements across DME, pharmacy, and outpatient medical benefits; provide guidance on reimbursement methodologies and regulatory interpretation
• Manage team workload, priorities, and resource allocation, balancing operational execution with strategic initiatives
• Accountable for team performance and results, including coding accuracy, denial reduction, audit outcomes, and revenue optimization
• Lead and oversee formulary, financial, and compliance analyses to identify denial drivers, coding variances, and revenue leakage; implement corrective actions to mitigate risk
• Drive cross-functional collaboration with operations, coding, clinical, and compliance stakeholders to resolve billing, reimbursement, audit, and denial-related issues
• Support audit readiness and lead efforts related to audit defense and appeals, ensuring defensible documentation and timely response to internal and external findings
• Own development, tracking, and reporting of key performance metrics (e.g., coding accuracy, denial trends, audit outcomes, revenue performance) to drive continuous improvement
• Establish and maintain policies, standard workflows, and training to ensure consistent, scalable, and compliant formulary and revenue cycle operations
• Lead complex projects requiring critical thinking, regulatory interpretation, and sound decision-making

Requirements

We’re looking for someone with a growth mindset and a passion for learning. You might be a great fit if you:

• Thrive in complex environments that require interpreting regulatory requirements and translating them into practical, operational solutions
• Exercise strong, independent judgment in both structured and ambiguous situations, balancing compliance, risk, and business outcomes
• Navigate shifting priorities with ease, using data and insight to make confident, timely decisions
• Take ownership of outcomes and care deeply about delivering an accurate, compliant, and high-quality customer experience

Skills and experience

• Bachelor’s degree required
• Advanced training in a healthcare-related field, with working knowledge of chargemaster management and/or coding and billing workflows
• Experience in revenue integrity, revenue cycle management, health system pharmacy operations, charge capture, or financial analytics
• Deep understanding of payer billing requirements and coding standards, including HCPCS, CPT, NDC mapping, and unit of service (UOS) accuracy, with understanding of CMS and OIG compliance requirements
• Demonstrated experience leading process improvement initiatives, including process design and implementation
• Proven ability to lead and coordinate cross-functional efforts to improve customer experience, financial outcomes, and compliance
• Strong verbal and written communication skills, with the ability to collaborate and communicate effectively across all levels of RCM, coding, and research teams
• Proficiency with Microsoft Office applications, including Excel, Word, Visio, and Access