Senior Director, Payer Relations and Contracting
Apply NowCompany: Oceans Healthcare
Location: Plano, TX 75025
Description:
Description
The Senior Director, Payer Relations and Contracting reports to the Vice President of Strategic Payer Relations and Performance. This position is responsible for overseeing the contractual life cycle of assigned payer agreements via the negotiation, renegotiation, monitoring and maintenance of the paper and the development and management of associated payer contact relationships. This position has a strong understanding of payer contract language and negotiates favorable contractual terms and rates in alignment with organizational business and financial needs. The Senior Director, Payer Relations navigates, researches, and resolves complex payer issues related, but not limited to, system loads, reimbursement, authorizations, appeals, and recoupments. This position develops strong internal collaborative relationships with operational, clinical, legal, and financial partners to achieve efficient, effective, and long-term resolution of payer issues. The Senior Director, Payer Relations contributes to the overall strategic direction of the department through an understanding of payer rates and reimbursement structure and associated impact to overall hospital financial performance, payer market dynamics and market share, and how payers acquire and are awarded new business across all financial classes. The Senior Director, Payer Relations has direct experience in the processes and procedures by distinct payer and line of business and articulates process detail and associated expectations to senior/executive leadership and hospital team members.
Essential Functions:
Negotiates, renegotiates, monitors, and maintains all managed care payer contracts in a transparent, centralized database that is reportable and accessible across the enterprise. Works collaboratively with key internal and external stakeholders to coordinate communication of contract terms and provisions. Completes education and training to various internal parties, including hospital administrative and clinical staff, regarding new or updated contract requirements. Manages the contract negotiation process to execute agreements with favorable contractual language and reimbursement terms. Reviews single case agreement terms, conditions, and rates for VP approval. Monitors payer scorecards and/or other reporting mechanisms to monitor overall payer performance. For value-based contracts, articulates Oceans' provider scorecard results to hospital and executive leadership. Participates in process improvement to enhance potential VB contract incentives. Responsible for coordinating and completing payer credentialing for new hospitals and services and recredentialing or existing locations and services. Assists in payer dispute resolution projects, settlements, etc. Performs other duties and projects as assigned.
Requirements
Educational / Experience Requirements:
The Senior Director, Payer Relations and Contracting reports to the Vice President of Strategic Payer Relations and Performance. This position is responsible for overseeing the contractual life cycle of assigned payer agreements via the negotiation, renegotiation, monitoring and maintenance of the paper and the development and management of associated payer contact relationships. This position has a strong understanding of payer contract language and negotiates favorable contractual terms and rates in alignment with organizational business and financial needs. The Senior Director, Payer Relations navigates, researches, and resolves complex payer issues related, but not limited to, system loads, reimbursement, authorizations, appeals, and recoupments. This position develops strong internal collaborative relationships with operational, clinical, legal, and financial partners to achieve efficient, effective, and long-term resolution of payer issues. The Senior Director, Payer Relations contributes to the overall strategic direction of the department through an understanding of payer rates and reimbursement structure and associated impact to overall hospital financial performance, payer market dynamics and market share, and how payers acquire and are awarded new business across all financial classes. The Senior Director, Payer Relations has direct experience in the processes and procedures by distinct payer and line of business and articulates process detail and associated expectations to senior/executive leadership and hospital team members.
Essential Functions:
Requirements
Educational / Experience Requirements:
- Bachelor's Degree in a related field such as finance, patient accounting, business development or experience equivalent.
- Demonstrated experience in the negotiation of complex facility and physician payer agreements with favorable language and reimbursement terms achieved.
- Understanding of managed care principles, payer contracts, reimbursement methodologies (DRG, per diem, % of LOB allowable, case rates, incentive and penalty components of value-based contracts), healthcare billing requirements, and managed care processes (credentialing, loading, disputes, appeals, etc.) as differentiated by line of business.
- Strong interpersonal and communication skills. Uses oral and written communication means to effectively convey ideas in a clear, articulate manner with internal and external parties, which include executive leadership, attorneys, payer leadership and operational subject matter experts.
- Demonstrates initiative to continually enhance understanding of the changing healthcare market by state and local regions.
- Exhibit's ability to work independently and is self-directed.
- Demonstrated experience building strong relationships with counterparts and leadership at various payers/plans. Experience in heavy interaction via phone, email and in person required.
- Advanced skills in Outlook, MS Word, MS PowerPoint, MS Excel, and Smartsheet.
- Familiarity with PowerBI tools.