Director, Payor Relations

Pediatric Associates was founded in Hollywood, FL in 1955. The same clinician-led, evidence-based, medical home passion is a unifying driver for those who join Pediatric Associates Family of Companies. The Pediatric Associates Family of Companies is a growing team of Pediatricians and Pediatric Care Teammates who are excited to be part of the first nationwide Pediatric Primary Care Medical Home. We further our uniqueness by ensuring the clinician voice is leading our medical home innovations.

PRIMARY FUNCTION

The Director of Payor Relations is responsible for creating, maintaining, and managing payor relationships within one of the PA Family of companies, directing all regional National Contracting initiatives, strategic planning, contract negotiations to include Risk and Value-Based Contracting, acquisition contracting strategies through implementation, and the development of payor partnerships. Reports directly to the regional Market President and works closely with the SVP of Payor Strategy.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This list may not include all of the duties that may be assigned.

Responsible for understanding and reporting on the commercial and Medicaid payor landscape in each state, including the regulatory environment for the state Medicaid program.

Setting up, in conjunction with the Market President and the SVP, Payor Strategy, our contracting approach to each market

Obtains, reports on and monitors the financial performance of all contractual arrangements and leads discussions with payors regarding contract performance and financial opportunities.

Performs payor-related due diligence activities with regards to prospective acquisition targets; actively manages the integration of acquired practices

Negotiates Risk, Value-Based, Fee-for-service, and Capitation contract rates/terms/language/provisions with payors to maximize reimbursement, reduce exposure, and improve operational efficiencies.

Evaluates payor incentive and bonus programs and identifies opportunities to ensure the organization is positioned to maximize potential incentive earnings.

Develops and manages department policies and procedures to ensure rate renegotiations upon renewals, contract performance management, and contract administration efficiencies

Identifies contracting opportunities within existing payor Agreements and fee schedules to maximize potential reimbursement

Researches, analyzes and reports on market trends in support of organizational strategic objectives.

Develops and maintains strong payor relationships.

Performs special projects as requested/all other duties as assigned.

Performs rate evaluation based on modeling and analysis and evaluates/monitors contract performance and contract compliance.

Other duties as assigned.

SUPERVISORY RESPONSIBILITIES

• Manages and develops the regional Payor Relationship Manager Team. Provides ongoing training, performance feedback, and avenues for professional development.
• Establish Team Goals and team performance KPIs.

QUALIFICATIONS

EDUCATION:
A bachelor's degree in healthcare administration or business is required. Master's degree preferred.
A minimum of 5 years of related experience will be commensurate with education.

EXPERIENCE:

• Minimum of 7 years' of combined payor and provider experience required.
• Previous healthcare experience required.

KNOWLEDGE, SKILLS AND ABILITIES

• In-depth understanding of contract parameters, reimbursement methodologies, contract language and performance.
• Knowledge in Risk and Value Based Contracting
• Effective strategic planning and organizational skills
• Knowledge of Statewide Medicaid Managed Care programs and Commercial payors
• Proficient in research, analysis, and interpretation of financial data and trends
• Knowledge of reimbursement methodologies and CPT, ICD10, RBRVS, and capitation.
• Knowledge of claims, credentialing, and loading processes
• Advanced Microsoft Office skills
• Effective oral and written communication and negotiating skills.
• Ability to manage multiple priorities and projects.
• Strong interpersonal skills
• Ability to influence others

LICENSURE/CERTIFICATION:

*Upon hire, and for the duration of the employment period driver's license must be active and valid.*

TYPICAL WORKING CONDITIONS

• Non-patient facing
• May be either full-time remote or rotate working in the office.
• Must be U.S. based.
• Indoor Work
• Operating Computer
• Reach Outward
• Reach above Shoulder
• Lift/Carry 11-20lbs.
• Standing
• Sitting
• Traveling
• Walking
• Bending
• Manual Dexterity

OTHER PHYSICAL REQUIREMENTS

• Vision
• Sense of sound
• Sense of touch
• Ability to wear Personal Protective Equipment (PPE)

PERFORMANCE REQUIREMENTS

Adhere to all organizational information security policies and protect all sensitive information, including but not limited to PHI (Protected Health Information) and ePHI, in accordance with organizational policy, federal, state, and local laws and regulations.

Comply with all federal, state, and local laws & regulations in the states where the Pediatric Family of Companies operates.

The Pediatric Associates Family of Companies an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.