DIRECTOR OF PAYER STRATEGY AND CONTRACTING

Overview

The Director of Payer Strategy and Contracting is responsible for the development, negotiation, implementation, and management of all payer contracts, following the transition from an externally managed Clinically Integrated Network (CIN) model to an internally governed contracting function. This key leadership role serves as the enterprise lead for payer strategy, contract economics, and payer performance management, ensuring that these efforts are in alignment with the organization's financial goals, clinical strategy, access objectives, and revenue cycle operations.

The Director works closely with the AVP of Revenue Cycle to ensure managed care contracting is integrated with downstream revenue integrity initiatives, denial prevention efforts, utilization management, and strategies for optimizing reimbursement.

Core Responsibilities

Contracting Strategy & Negotiation

• Lead the negotiation, renewal, and execution of all payer contracts, including those with commercial payers, Medicare Advantage, Medicaid managed care, and employer or direct contracts.
• Oversee the transition of payer relationships and contracting authority from the CIN or third-party entity to the hospital, ensuring network participation and continuity are maintained.
• Develop and negotiate a variety of reimbursement methodologies, such as fee-for-service arrangements (e.g., DRG, APC, case rate, percent of charge), value-based arrangements (including quality incentives and shared savings or losses), and risk-based or capitated models where appropriate.
• Establish contract standards, templates, and guardrails in collaboration with the Legal and Finance departments.

Payer Relationship & Escalation Management

• Serve as the primary executive contact for payer counterparts.
• Manage escalated issues related to underpayments, systemic claim errors, authorization and medical necessity disputes, policy interpretation, and contract compliance.
• Coordinate and lead payer performance reviews and quarterly business reviews (QBRs).

Financial Modeling & Analytics (Enhanced Scope)

• Take ownership of pre-negotiation and post-contract financial modeling in partnership with Finance and Revenue Integrity teams.
• Evaluate contract performance using key metrics such as net revenue yield, case mix and DRG/APC reimbursement trends, denials, downcoding, severity erosion, and utilization management impacts.
• Translate contract terms into actionable requirements for the revenue cycle, including CDM, chargemaster logic, and contract loading validation.

Contract Implementation & Lifecycle Management

• Ensure accurate interpretation, loading, and validation of contracts within billing and contract management systems.
• Develop workflows for ongoing contract compliance monitoring, amendment tracking, rate escalation, and term renewals.
• Partner with Patient Financial Services, HIM, CDI, and Revenue Integrity to align documentation and billing practices with contract requirements.

Regulatory & Compliance Oversight

• Ensure all payer contracts comply with CMS and state Medicaid regulations, network adequacy and access requirements, and provisions of the Price Transparency and No Surprises Act.
• Monitor changes in regulatory and payer policies, and proactively assess their financial and operational impacts on the organization.

Strategic Alignment & Governance

• Serve as a key contributor to enterprise revenue cycle and managed care governance forums.
• Align payer strategy with service line growth plans, physician alignment strategies, and initiatives for access and market expansion.
• Provide executive-level insights and recommendations to senior leadership to support strategic decision-making.

Leadership & Team Development

• Build and lead an internal payer contracting and analytics team as responsibilities transition from the CIN to the hospital.
• Establish clear roles, competencies, and performance metrics for contracting staff.
• Act as the internal subject matter expert on reimbursement, managed care strategy, and payer behavior.

Required Education/Licensure:

• Bachelor’s degree in Healthcare Administration, Finance, Business, or a related field

Preferred Education/Licensure

• Master’s degree preferred

Preferred Experience

• Experience with transitioning contracting functions from CINs, MSOs, or third-party administrators to an internal hospital model.
• Familiarity with contract modeling tools, contract management systems, and payer performance dashboards.
• Experience working closely with Legal, Compliance, HIM/CDI, and Revenue Integrity teams.

Required Experience

• Demonstrated experience in leading payer negotiations and managing complex contracts.
• Strong analytical skills, with the ability to interpret financial models and translate findings into executive recommendations.
• Deep knowledge of commercial and government payer reimbursement, value-based payment models, and revenue cycle workflows and financial controls.

Key Competencies For Success

• Strategic negotiation and influence
• Financial acumen and data-driven decision-making
• Cross-functional leadership and collaboration
• Executive communication and escalation management
• Change management and operational discipline

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties within scope of practice of role.

Our Commitment To You

Riverside Healthcare offers a comprehensive suite of Total Rewards: benefits and nationally rated employee well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more - so your journey at and away from work is remarkable. Our Total Rewards package includes:

Compensation

• Base compensation within the position’s pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Opportunity for annual increases based on performance

Benefits - .5 To 1.0 FTE

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Health Savings and Flexible Spending Accounts for eligible health care and dependent care expenses
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program
• Leadership Development

Employee Health Requirements

Exposure/Sensory Requirements:

Exposure To

• Chemicals: Refer to MSDS Sheets
• Video Display Terminals: Extreme
• Blood and Body Fluids: None
• TB or Airborne Pathogens: None

Sensory Requirements (speech, Vision, Smell, Hearing, Touch)

• Speech: Needed for presentations/training, telephone communication, facilitate meetings.
• Vision: Needed to read memos and literature
• Smell: Helpful to note presence of electrical/fire hazard.
• Hearing: Needed for telephone communication, meetings, alarms and listening to visitor/employee concerns.
• Touch: Needed to write, computer entry, filing.

Activity/Lifting Requirements

Percentage of time during the normal workday the employee is required to:

• Sit: 90%
• Twist: 0%
• Stand: 10%
• Crawl: 0%
• Walk: 0%
• Kneel: 0%
• Lift: 0%
• Drive: 0%
• Squat: 0%
• Climb: 0%
• Bend: 0%
• Reach above shoulders: 0%

The weight required to be lifted each normal workday according to the continuum described below:

• Up to 10 lbs: Occasionally
• Up to 20 lbs: Not Required
• Up to 35 lbs: Not Required
• Up to 50 lbs: Not Required
• Up to 75 lbs: Not Required
• Up to 100 lbs: Not Required
• Over 100 lbs: Not Required

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.):

Maximum consecutive time (minutes) during the normal workday for each activity:

• Sit: 120
• Twist: 0
• Stand: 10
• Crawl: 0
• Walk: 0
• Kneel: 0
• Lift: 0
• Drive: 0
• Squat: 0
• Climb: 0
• Bend: 0
• Reach above shoulders: 0

Repetitive Use Of Hands (Frequency Indicated)

• Simple grasp up to 10 lbs. Normal weight: constant
• Pushing & pulling Normal weight:
• Fine Manipulation: Excessive typing and data entry

Repetitive use of foot or feet in operating machine control: None

Environmental Factors & Special Hazards Environmental Factors (Time Spent)

• Inside hours: 8
• Outside hours : 0
• Temperature: Normal Range
• Lighting: Average
• Noise levels: Average
• Humidity: Normal Range
• Atmosphere: Normal Range

Special Hazards: None

Protective Clothing Required: None

Pay Range

USD $72.08 - USD $99.20 /Hr