US:NV:Carson City Payer Relations
Full Time Standard Office Hours
Summary
The Director of Payer Relations is responsible for leading the organization's payer strategy, contract negotiations, and ongoing payer performance management to optimize reimbursement and support financial sustainability. This role serves as the primary liaison between the organization and commercial payers, driving strategic partnerships, ensuring contract compliance, and identifying opportunities to enhance revenue performance. The Director collaborates closely with Finance, Revenue Cycle, and Clinical Leadership to align payer arrangements with organizational goals, including value-based care initiatives, while proactively monitoring payer behavior, mitigating revenue leakage, and ensuring accountability to contract terms.
Qualifications
Required:- Bachelor's Degree in Healthcare Administration, Business Administration, Finance, or related field
- 7-10 years of progressive experience in healthcare payer relations, managed care contracting, or revenue cycle
- 3-5 years of experience in leadership
- Demonstrated experience leading complex payer negotiations and contract strategy
Preferred:- Master's Degree in related field.
- Experience with value-based care models and risk-based reimbursement arrangements
- 3-5 years of experience in payer contracting
- Experience collaborating cross-functionally with Finance, Revenue Cycle, and Clinical Leadership
Essential Functions
- Lead negotiations with commercial payers, including rates, escalators, and contract terms (e.g., carve-outs, amendments).
- Develop and execute multi-year payer strategies aligned with organizational financial and margin goals.
- Evaluate and structure reimbursement models, including fee-for-service and value-based arrangements.
- Assess and manage risk-based models such as shared savings and downside risk agreements.
- Oversee the full contract lifecycle, including financial modeling, negotiation, execution, and renewal.
- Partner with Finance and Decision Support to develop and oversee net revenue impact models.
- Analyze reimbursement methodologies, including case rates, DRG, and APC structures.
- Identify and address denial trends and payer behaviors impacting reimbursement.
- Monitor underpayments and ensure alignment with negotiated contract terms.
- Collaborate with Revenue Cycle to optimize reimbursement performance and resolve discrepancies.
- Serve as the primary contact for key payer relationships, including UnitedHealthcare, Aetna, Blue Cross Blue Shield/Anthem, and regional health plans.
- Lead quarterly business reviews (QBRs) and ongoing issue resolution meetings with payer partners.
- Manage network participation status (in-network/out-of-network) and support market positioning strategies.
- Foster strong, collaborative relationships to support contract performance and strategic alignment.
- Structure and manage value-based payment arrangements, including bundled payments, shared savings programs, and capitation models.
- Partner with Clinical Leadership and Care Management teams to align financial incentives with patient outcomes.
- Monitor and report on quality metrics and cost benchmarks tied to payer agreements.
- Develop and present executive-level reporting on payer mix, yield, and net revenue by payer.
- Track and analyze contract performance against expectations and organizational targets.
- Provide strategic insights and recommendations to senior leadership to inform decision-making.
- Performs other related duties as assigned.
