Plutus Health Inc. is seeking a skilled EDI Consultant with specialized experience in healthcare claim transactions to support our Data Integration (DI) Review & Validation efforts. The ideal candidate will have a strong background in 837P professional claim formats and CMS-1500 form mappings, with the ability to assess and validate system logic against payer-specific requirements. Key Responsibilities: Conduct detailed reviews of 837P (Professional) EDI transactions to ensure data integrity and format accuracy. Validate mappings to CMS-1500 claim forms , ensuring alignment between electronic and paper-based formats. Review and confirm correct population of provider fields (e.g., Rendering NPI, Supervising NPI ) at both line-item and claim levels . Identify, document, and communicate any gaps, mismatches, or inconsistencies between system-generated data and payer requirements. Collaborate with cross-functional teams (EDI developers, business analysts, QA) to provide feedback and recommend corrections. Participate in user acceptance testing (UAT) and post-deployment validation to ensure implementation success. Stay updated on HIPAA EDI standards and payer-specific guidelines related to 837P/CMS-1500 submissions. Required Qualifications: Proven experience working with 837P transactions and CMS-1500 claim formats. Strong understanding of HIPAA EDI standards , claim data elements, and provider field logic. Hands-on experience with claim validation tools, EDI mapping, and system configuration review. Familiarity with payer-specific submission requirements and business rules. Ability to analyze large data sets and identify discrepancies or issues efficiently. Excellent documentation, communication, and collaboration skills. Preferred Qualifications: Experience with clearinghouses or payers. Familiarity with 837I or other transaction sets (e.g., 835, 999, 277CA). Prior work with EHR/EMR or billing system integrations.
Chief of Staff – India Location: Bengaluru / India Reports to: CEO About Plutus Health Plutus Health Inc. is an Inc 5000, SMU Dallas 100 Fastest growing, EY Entrepreneur of the year Southwest Finalist. We are a tech enabled healthcare revenue cycle management outsourcing firm that has been in the industry for 17 years. We offer end-to-end business solutions to Enterprise healthcare providers in the United States, ensuring that all our services are fully compliant with HIPAA regulations. We are a leading provider of tech-enabled Revenue Cycle Management (RCM) solutions for healthcare providers, with 1,600+ employees across the US and India . Role Overview The Chief of Staff—India is a strategic and operational leader partnering closely with the CEO to drive priorities, lead key projects, coordinate global operations, and foster performance and culture across India and the broader Plutus Health network. This role is the central point between the India executive team and CEO, ensuring seamless execution of both local and global strategies. Key Responsibilities & KRAs 1. Strategic Planning & Execution · Partner with CEO and India management to implement Plutus Health’s vision using proven project management and change acceleration techniques. · Translate global objectives into actionable initiatives for India teams; regularly track, report, and recalibrate execution as needed. 2. India Operations & Leadership · Oversee end-to-end execution of RCM projects, automation, process improvement, compliance, and operational performance with a sharp India market focus. · Lead cross-functional teams (claims, denials, tech, client services), ensuring high-quality and efficient delivery in a rapidly-scaling environment. 3. Cross-Border Integration & Global Support · Facilitate collaboration and alignment between US and India operations, bridging cultural and business practices to optimize global workflows. · Represent India offices in global strategy sessions and proactively raise India-specific needs, challenges, and opportunities. 4. Executive & Stakeholder Communication · Serve as the India-based advisor and gatekeeper to the CEO, prioritizing information and initiatives for executive attention. · Prepare executive briefings, board packs, and key internal/external communications on behalf of the CEO and India leadership. 5. Talent, Culture & Change Management · Drive talent planning, workforce development, skill-building, and cultural initiatives across India. · Foster a high-performance, collaborative, and innovative culture that bridges India and global best practices. 6. Risk, Compliance & Reporting · Track and report KPIs on RCM performance, project delivery, client satisfaction, and workforce engagement. · Assure India operations meet regulatory and contractual obligations, and proactively mitigate operational or compliance risks. Qualifications · Master's degree / MBA in business, healthcare admin, operations, or related field from a Premier university ( IIT/IIM/REC or similar) · 8 + years’ experience in US healthcare RCM outsouricng, IT Services or Technology outsouricng , BPO or similar operations, including leadership roles in India/global settings. . Strong understanding of AI, Automation, Analytics · Demonstrated ability to lead, motivate, and influence teams in a cross-cultural, multi-country business. · Strong project management, process improvement, and data-driven problem-solving skills. · Excellent communication, executive presence, and cultural fluency related to both Indian and Western business environments. Plutus Health Offers · Direct impact on India and global strategy at a growth-focused RCM leader. · High-visibility executive role, career advancement, and cross-border networking opportunities. · Inclusive, tech-driven workplace and competitive total rewards.
ABOUT PLUTUS HEALTH Plutus Health is a Dallas-headquartered healthcare revenue cycle management company serving providers across multiple specialties. With 1,600+ employees in the United States, India, and the Philippines, we deliver end-to-end RCM services including medical billing, credentialing, payer enrollment, and contracting. POSITION OVERVIEW The Director of Credentialing & Contracting will provide strategic and operational leadership for provider credentialing, re-credentialing, payer enrollment, and payer contract negotiation. This senior role requires deep expertise in healthcare credentialing and payer contracting, strong team leadership skills, and the ability to implement technology and automation to drive efficiency, compliance, and revenue impact across multiple clients and payer relationships. KEY RESPONSIBILITIES Strategic Leadership & Operations Develop and execute credentialing and contracting strategies aligned with company growth. Lead and mentor a large, offshore-heavy team of credentialing specialists and contracting analysts. Define and track KPIs, SLAs, and quality metrics; drive continuous improvement. Design scalable processes to support rapid expansion. Partner with RCM operations, sales, finance, legal/compliance, and executive leadership. Provide executive-level reporting on credentialing status, payer performance, and revenue impact. Credentialing & Provider Enrollment Oversee end-to-end credentialing for 700+ provider applications monthly across specialties. Manage initial credentialing, re-credentialing, and enrollment for Medicare, Medicaid, and commercial payers. Achieve 98%+ SLA compliance and target turnaround times (90120 days initial; 6090 days re-credentialing). Ensure accurate primary source verification (licenses, DEA, board certifications, education, work history). Oversee CAQH profile management and hospital privileging across multiple facilities. Maintain strong relationships with payer enrollment teams to expedite approvals. Implement credentialing technology and automation to reduce manual work. Technology, AI & Automation Lead implementation of Agentic AI, RPA, and workflow automation to reduce processing time by 2030%. Deploy AI tools for application completion, document extraction, and data validation. Implement automated roster management, license monitoring, and re-credentialing alerts. Use contract management platforms for rate tracking, renewal alerts, and fee comparisons. Integrate credentialing systems with billing platforms to ensure clean provider data. Evaluate and implement credentialing and contract management software; build dashboards for real-time metrics. Champion digital transformation initiatives across credentialing and contracting. Payer Contracting & Negotiations Lead payer negotiations for commercial, Medicare Advantage, and Medicaid managed care plans. Analyze reimbursement rates using technology platforms; execute strategies to improve rates by 25%. Review and negotiate participation agreements (fee schedules, payment terms, denial/appeal processes, credentialing clauses). Manage contract renewal cycles with proactive planning and automated tracking. Maintain a centralized contract database with rate tracking and expiration alerts. Identify underperforming contracts using analytics and drive renegotiation or termination. Ensure accurate contract loading into billing systems; negotiate carve-outs for high-volume CPT codes. Regulatory Compliance & Quality Ensure compliance with NCQA, URAC, CMS, The Joint Commission, and state-specific standards. Maintain expertise in NPDB, OIG LEIE, SAM.gov, and state sanctions. Oversee credentialing committee processes and documentation. Conduct regular audits of files and contracts; implement corrective actions. Ensure HIPAA compliance and manage delegation oversight activities for IPAs and MSOs. Client & Stakeholder Management Serve as primary escalation point for complex credentialing and contracting issues. Conduct client presentations on status, performance, and strategic recommendations. Support sales during new client implementations and RFPs. Build trusted relationships with provider leadership and practice administrators. Set and manage expectations around timelines and negotiation outcomes. Financial Analysis & Revenue Optimization Analyze payer mix and reimbursement to identify revenue opportunities. Perform fee schedule comparisons and build business cases for renegotiations. Track contract value realization and underpayments using analytics tools. Model financial impact of contract changes and collaborate with finance and RCM teams. REQUIRED QUALIFICATIONS 1215+ years of progressive experience in US healthcare credentialing and provider enrollment. 5+ years leading teams of 50+ in credentialing and/or contracting. Proven experience managing 500+ credentialing applications monthly at scale. Deep knowledge of Medicare, Medicaid, and commercial payer requirements across multiple states. Demonstrated success negotiating payer contracts with measurable rate improvements. Hands-on experience implementing AI, RPA, or automation in credentialing or contract workflows. Expert knowledge of CAQH, PECOS, NPPES, and major payer portals (UHC, Anthem/BCBS, Cigna, Humana, Aetna). Strong understanding of fee schedules, reimbursement methodologies, and payment terms. Experience with NCQA/URAC/Joint Commission standards. Advanced Excel skills (data analysis, pivot tables, complex formulas); familiarity with BI tools preferred. Excellent client-facing communication and executive presentation skills. Bachelor's in Healthcare Administration, Business, or related field; Master's preferred. Ability to work US business hours (evening/night shift from India). PREFERRED QUALIFICATIONS NAMSS certification (CPCS or CPMSM). Track record leading automation projects delivering 20%+ efficiency gains. Background in healthcare RCM or medical billing. Experience managing credentialing for numerous specialties and multi-facility groups. Hands-on experience with credentialing platforms (e.g., Symplr, Cactus, CredentialStream, MD-Staff) and contract management tools. Knowledge of value-based contracts and ACO/CIN credentialing. Experience with delegation oversight for IPAs/MSOs and offshore team management. Familiarity with AI/ML in healthcare operations (document extraction, workflow automation, predictive analytics). TECHNICAL COMPETENCIES Credentialing: CAQH ProView, PECOS, NPPES, state Medicaid systems. Verification: NPDB, OIG LEIE, SAM.gov, SSA Death Master File, Medicare Opt-Out, state licensing boards. Payer Portals: Major commercial payers, Medicare, Medicaid MCOs. Automation & AI: RPA platforms, AI document extraction, workflow automation. Reporting: Advanced Excel; experience with Power BI/Tableau a plus. LEADERSHIP COMPETENCIES Strategic thinking and ability to translate business goals into execution. Strong people leadership: hiring, coaching, and performance management. Proven ability to build and scale high-performing teams. Excellent negotiation and stakeholder management skills. Data-driven decision making and strong financial acumen. Change management and technology adoption experience. Executive presence and strong communication skills. Problem-solving and innovation mindset. KEY SUCCESS METRICS 98%+ SLA achievement and on-time credentialing. Target credentialing turnaround times met or improved. 2030% reduction in manual effort via automation. 100% CAQH accuracy and clean audits. 25% improvement in renegotiated payer rates. Zero critical compliance violations and minimal client escalations. High client satisfaction and strong team engagement. REPORTING STRUCTURE Reports to: VP of Revenue Cycle Management Direct Reports: 35 credentialing/contracting managers Team: 50+ credentialing specialists and contracting analysts Partners: RCM operations, finance, sales, client success, legal/compliance, IT/automation COMPENSATION & BENEFITS Competitive salary: ?3545 LPA (based on experience). Performance bonus up to 20% of base. Night shift allowance for US hours. Comprehensive health insurance for employee and dependents. NAMSS certification support and continuing education. Hybrid model (3 days office / 2 days remote) in Bangalore (or Coimbatore). Leadership development and exposure to US leadership; potential travel. WORK ENVIRONMENT Location: Bangalore, India (alternate: Coimbatore). Fast-paced, client-focused, deadline-driven environment with high accountability and strong emphasis on innovation. HOW TO APPLY Send the following to [HIDDEN TEXT] with subject line: Director Credentialing & Contracting [Your Name] Resume detailing credentialing volumes, payer contracts, and automation projects. Cover letter addressing: (a) largest credentialing operation managed, (b) most successful payer negotiation, (c) automation/AI projects led, (d) leadership philosophy. References from prior credentialing or healthcare leadership roles.