Overview

The Director, Payer Strategy & Contracting leads the development, negotiation, implementation, and ongoing management of payer agreements across the Central Health System, including Medicaid, Medicare, Managed Care Organizations, and commercial payers. This role is responsible for securing financially sustainable, operationally sound contracts that align with organizational goals, support population health priorities, and optimize reimbursement across fee-for-service and value-based care arrangements.

 

The Director partners with executive leadership, finance, revenue cycle, clinical operations, compliance, population health, and analytics teams to evaluate contract performance, model financial scenarios, mitigate risk, support payer relationships, and drive continuous improvement in reimbursement strategy and contract operations. This role also provides oversight for payer enrollment activities and ensures payer-related processes support timely access, accurate reimbursement, and regulatory compliance.

Responsibilities

Essential Functions

Payer Contract Strategy & Negotiation:- Leads payer contracting strategy, negotiations, renewals, amendments, and escalations with Medicaid, Medicare, Managed Care Organizations, and commercial payers.- Develops contracting strategies that support organizational priorities, strengthen payer partnerships, maximize reimbursement, and promote long-term financial sustainability.- Evaluates contract terms related to reimbursement methodologies, payment policies, quality requirements, performance expectations, reporting obligations, and operational impacts.- Leads rate negotiations and recommends contract structures that support both financial and operational goals.- Ensures payer agreements are reviewed for alignment with applicable federal, state, and program-specific requirements.

 

Value-Based Care and Alternative Payment Models:- Designs, negotiates, implements, and monitors value-based care arrangements, including shared savings, payfor- performance, quality incentive, bundled payment, capitation, and other alternative payment models.- Develops payer proposals for value-based or alternative payment arrangements based on organizational strategy, data analysis, financial modeling, operational readiness, and risk tolerance.- Partners with population health, quality, finance, clinical operations, and analytics teams to model risk corridors, attribution methodologies, benchmark methodologies, performance measures, and projected financial impact.- Monitors value-based care performance, including quality metrics, cost performance, utilization trends, incentive payment projections, and related payer reporting requirements.

 

Financial Performance and Contract Analytics:- Partners with Finance to evaluate contract terms, forecast expected revenue, assess reimbursement performance, and identify potential financial risk exposure.- Uses data and analytics to identify underperformance trends, reimbursement gaps, payer payment issues, and opportunities for improvement.- Supports cost modeling, contract performance dashboards, financial impact assessments, and executive-level reporting related to payer contract performance.- Prepares and presents contract performance updates, recommendations, and executive briefings to support informed decision-making.

 

Payer Relationship and Stakeholder Governance:- Serves as a primary liaison with external payer contracting teams and supports productive, collaborative payer relationships.- Leads cross-functional governance related to payer performance, contract implementation, reimbursement issues, and operational barriers.- Coordinates with Revenue Cycle, Finance, Compliance, Clinical Operations, Population Health, and other internal stakeholders to ensure contract terms are implemented and operationalized effectively.- Provides internal education and guidance regarding payer contract terms, reimbursement methodologies, payment policies, and operational requirements.- Collaborates with revenue cycle teams to resolve payer payment issues, denials, reimbursement disputes, and other contract-related operational concerns.

 

Payer Enrollment Oversight:- Provides leadership and oversight for payer enrollment activities, including applications, revalidations, enrollment maintenance, and related payer requirements.- Manages the Payer Enrollment Specialist and ensures payer enrollment processes support organizational access, reimbursement, compliance, and operational needs.- Ensures payer enrollment activities are coordinated across applicable locations, providers, and payer programs.

 

Compliance, Documentation, and Regulatory Alignment:- Ensures payer agreements align with applicable federal and state regulations, including Medicaid managed care requirements, Medicare guidelines, value-based care reporting requirements, and other payer-specific obligations.- Ensures appropriate alignment of payer contracts with FQHC reimbursement methodologies and applicable grant, funding, or program requirements, where applicable.- Maintains accurate payer contract files, rate schedules, payer documentation, and related regulatory records.- Supports audits, regulatory reviews, payer inquiries, and compliance-related requests as needed.

Qualifications

MINIMUM EDUCATION: Bachelor's Degree (higher degree accepted) in Business, Healthcare Administration, Finance, or related field

 

MINIMUM EXPERIENCE:

-7 years of progressive experience in payer contracting within healthcare.

-Demonstrated experience negotiating with Medicaid, Medicare, Managed Care Organizations, and commercial payers.

-Proven experience structuring, implementing, or managing value-based care arrangements or alternative payment models.