Director, Payer Relations (32932) in Southlake, Texas at GI Alliance

Director, Payer Relations (32932)
Job DetailsJob Location: GIA Cedar Ridge Admin - Southlake, TX 76092
Position Type: Full Time
Job Shift: Day
Description

Description

Position purpose
Responsible for initial negotiation and final implementation of payer or managed care contracts (e.g., HMO, PPO, EPO, government, medical group, capitation contracting) for The Specialty Alliance (TSA). Responsible for strategic planning; document management; relationship management and contracting activities related to managed care contracting. The position is also responsible for contract oversite and training to ensure proper execution of contracts.

This Director of Payer Relations position serves as an integral member of the Payer Relations and Contracting Team and reports to the Executive Director of Payer Relations. This role is a key contributor to the development of the strategic direction and is accountable for the management of contracting and network management activities for multiple local geographies. The customer base includes TSA’s key target customers: physicians, employers/employees, and health plans/insurance companies.

Responsibilities/Duties/Functions/Tasks:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Directly manages the payer contracting for an assigned geography. Participates and leads in contract negotiations and pricing improvements to drive profitable revenue growth.

Demonstrates comprehensive knowledge of providers, healthcare systems, and payers in an assigned geographic area through understanding the interrelationships as well as the competitive landscape.

Manage strategic positioning and increasingly complex contracts including negotiations for fee for service contracts and identify opportunities for value-based reimbursement and/or risk arrangements with payers.

Maintain a high level of expertise in pricing arrangements, contract requirements/contract language, value-based initiatives with the various health plans.

Proactively builds relationships that nurture provider and payer partnerships and seeks broader value-based business opportunities to support the local strategy.

Maintains effective communication with TSA internal staff including but not limited to, Operations, Credentialing, Legal, Compliance, Marketing, and local leadership within the practice location.

Supports and provides direction to Finance for analytics required for the contracting initiatives and contract strategies. Analyze financial reports to determine the impact of contract negotiations, updates to fee schedules, etc.

Assists in resolving elevated and complex payer complaints. Research problems and negotiates with internal/external partners to resolve highly complex and/or escalated issues.

Initiate and lead the process of development, implementation, monitoring and management of all managed care agreements.

Evaluate opportunities for new contracting strategies with performance-based or value-based contracting. Evaluate ACO’s in markets where TSA performs services. Determine strategic ACO partners and align with the ACO’s to increase patient volume and revenue for TSA as appropriate.

Work with health plans and present information to Executive Director of Payer Relations, CEO, CFO, COO, and GIA physician leadership to finalize contract rates.

Ensure new contract rates are loaded and claims payments are made correctly according to the contracts.

Evaluate existing agreements to ensure they are structured to maximize profitability and limit the exposure to financial decreases.

Maintain updated records and price schedules.

Manage process for timely renewals of contracts in collaboration with the Operations and Finance teams.

Responsible for educating the TSA provider offices on any specific contract initiatives, such as performance-based reimbursement or value-based program requirements. Educate provider office staff to ensure they are aware of any health plan policies and procedures.

Work with credentialing staff to ensure TSA practitioners are loaded in the health plans correctly.

Conducts presentations to all levels of the organization to include concepts, proposals, business cases, strategies, measurements, and/or outcomes.

You will participate in developing long-range goals and objectives in collaboration with operating units within your market.

Maintain confidentiality of company business.

Provide tracking and analysis of contract performance to executive leadership.

Act a contract subject matter expert.

Compliance with HIPAA, TSA policies, and all related federal and state regulations.

Travel as needed.

Other duties as assigned.

Qualifications

Qualifications

EDUCATION: Master’s degree in Healthcare Administration, Business Administration, Economics, or related field required. Significant industry experience will be considered in lieu of a Bachelor’s degree. MBA or MHA preferred.

EXPERIENCE: Minimum of ten years progressive experience in contract management, provider contract negotiation, healthcare leadership, and provider relations (health plan experience preferred).

Minimum of five years experience in a management role.

Performance Requirements:

Knowledge of the payers and providers within the West region (Arizona).

Knowledge of medical terminology and insurance practices.

Extensive knowledge of complex provider contracting and value-based or alternative payment models to include, financial analysis, credentialing, legal review, implementation, compliance, and utilization of data.

Thorough understanding of professional fee schedules/reimbursement methodologies.

Knowledge of managed care, Medicare, and Medicaid guidelines.

Prior experience managing direct reports and leading project teams in a non-centralized work environment preferred.

Demonstrated experience in seeking out, developing, and nurturing strong external relationships with payers/health insurance companies.

Team player with proven ability to develop strong working relationships within the organization.

The ability to influence through strong written and verbal communication skills. Experience with formal presentations.

Superior problem solving, decision-making, negotiating skills, contract language and financial acumen.

Knowledge and use of Microsoft Office tools

Skill in written and verbal communication.

Ability to plan, organize, prioritize, and direct the work of others.

Ability to establish and maintain effective working relationships with payers/managed care companies, internal employees, and leadership.

Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.

Work Environment: Work requires hand dexterity for office machine operation, stooping and bending to files and supplies, mobility to complete errands, or sitting for extended periods of time. Occasionally lifting files or paper weighing up to 20 pounds. Occasionally work environment may be very stressful.

Mental/Physical Requirements: Normal office environment. May view computer screens for long periods of time. Occasional evening or weekend work.