Director Of Payer Relations

Reporting to the AVP, Managed Care & Executive Director, PHO, the Director of Payer Relations plays a crucial role that demands a unique set of skills to ensure seamless interactions with insurance payers, PHO physician members, internal and external billing departments, and various other stakeholders. This highly visible position is primarily responsible for the escalation and resolution of facility and professional claims issues. These include, but are not limited to, contract or enrollment issues impacting billing and reimbursement, administrative issues impacting operations, and effective issues management and communication with key stakeholders through final and accurate payment. This position provides oversight to a team of Payer Relations Coordinators and serves as a liaison to the HSS and PHO Managed Care team.

Responsibilities:

• Oversees compliance of managed care companies and payment rules with negotiated contracts.
• Works closely with other members of the Managed Care team, Patient Financial Services, and/or Central Billing Office to identify trends and opportunities in outstanding Accounts Receivables for both PHO providers and facilities.
• Responsible for ensuring reports and updates (i.e. A/R, denials, etc.) are disseminated to departmental staff. This includes working with Patient Financial Services and other departments on the implementation and maintenance of departmental dashboard.
• Escalates issues as necessary to payer contacts for resolution as well as HSS contracting team. Recommends escalation as appropriate to senior management.
• Provides feedback on trends/patterned issues to Managed Care team to aid in negotiation and implementation of fee-for-service and value-based payer contracts across HSS and PHO.
• Assesses contract administrative terms and payer policies to advise leadership accordingly on measures of contract performance.
• Ensures key stakeholders are communicated to on contractual obligations, emerging trends stemming from contract performance, payer policy changes, and other related topics
• Maintains up to date knowledge on the healthcare market and timely initiatives
• Implement departmental policies, protocols and systems to enhance efficiency and effectiveness of workflows
• Possess strong leadership skills and demonstrate capability to inspire staff to pursue excellence in goals and productivity; capable of coaching and improving staff in need of professional development. Places high priority on overall team performance.
• Additional responsibilities as required to accomplish departmental goals.

Experience, Competencies, and Personal Characteristics:

Experience (minimum 7+ years) with payer or provider contracting and/or revenue cycle management. Major teaching/surgical hospital experience or health plan experience is highly desirable. Experience with EPIC or other comparable EMR systems preferred.

Experience with Salesforce preferred. Experience managing and leading a professional team. Experience dealing with physicians and their office/billing staff. Possesses key payer contacts and knowledge of payer resolution processes. Knowledge of the healthcare industry and payer reimbursement methodologies (both hospital and physician). Ability to work independently and collaboratively to solve complex problems The ability to influence and motivate others, as well as work collaboratively within a multi-stakeholder environment is required. Excellent verbal and written communication skills Excellent organizational and multi-tasking skills Is professional when dealing with stakeholders. Uses good judgement and takes a thoughtful approach to resolving and communicating issues.

Education:

Bachelor's degree in health or business administration, economics or related subject is required. Masters preferred.

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