We are looking for a National Director of Managed Care to join our growing team! This position will provide strategic leadership for managed care operations across the organization. This role drives patient access, referral growth, and revenue performance by developing payer partnerships, optimizing prior authorization processes, and strengthening collaboration among health plans, physicians, and hospital teams. The Director works closely with payer medical directors and clinical admissions teams to reduce barriers to admission, improve authorization outcomes, minimize denials, and support timely transitions of appropriate patients into inpatient rehabilitation.
Essential Functions
Minimum Job Requirements
- Serve as primary liaison to national and regional Medicare Advantage plans, promoting the clinical and financial value of inpatient rehabilitation services, and strengthening payer relationships.
- Partner with contracting teams to negotiate, implement, and monitor payer contracts, ensuring reimbursement structures appropriately reflect IRF requirements.
- Lead improvements to referral intake and prior authorization processes to accelerate referral decisions, reduce operational turnaround times, and increase timely admissions.
- Collaborate with clinical liaisons, case managers, and rehabilitation physicians to ensure documentation clearly supports admission and coverage requirements before submission.
- Intervene in complex or delayed authorization requests and facilitate reviews between payer medical directors and physicians to help resolve issues
- Lead strategic efforts to appeal payer denials, identify trends, and develop strategies, education, and processes that reduce further denials.
- Monitor and report key performance metrics including payer-specific referral-to-admission conversion rates, authorization turnaround times, denial rates, and length-of-stay variations.
- Collaborate with admissions, clinical, utilization review, revenue cycle, contracting, and hospital leadership teams to implement payer-specific action plans and drive measurable improvements in patient access, admissions, and reimbursement.
- Establish and lead regular meetings with key payers to address authorization challenges, resolve utilization issues, authorization challenges, and strengthen working relationships.
Minimum Education & Experience
- Bachelor’s degree in healthcare administration, business administration, nursing, or a related field required. Master’s Degree (MHA, MBA, MSN) preferred. Direct experience in healthcare leadership may be substituted for education on a year for year basis.
- 5 years’ progressive leadership experience in healthcare managed care, utilization review, or payer relations required.
- Experience with CMS medical necessity requirements and IRF experience preferred.
Required Licenses, Certifications, and/or Documentation
- Must maintain acceptable driving record, current driver’s license, and insurability
Required Knowledge, Skills, and Abilities
- Advanced knowledge of Medicare Advantage (Part C) utilization management structures, clinical guidelines, and prior authorization regulations.
- Comprehensive knowledge of post-acute operational models and CMS medical necessity requirements.
- Knowledge of payer types in the healthcare industry.
- Demonstrates effective conflict resolution in customer service.
- Ability to travel between markets
Physical Requirements over the Course of a Shift
- A significant amount of standing, often for prolonged periods of time
- Both gross and precise motor functions
- Sufficient manual dexterity to operate equipment and computer keyboard
- Close vision and the ability to adjust focus
