Vice President, Payer Contracting and Credentialing

Job Description

Job Description:ESSENTIAL FUNCTIONSPayer Strategy, Contracting & Reimbursement Serve as the enterprise executive owner of HOPCo’s payer strategy, setting the multi-year national and regional contracting roadmap across commercial, Medicare Advantage, Medicaid managed care and workers’ compensation payers, aligned with organizational growth, service line and market expansion strategies. Personally lead and direct high-impact negotiations with national and regional payers, including rates, payment methodologies, contract language and value-based arrangements, balancing near-term revenue optimization with long-term strategic positioning and in accordance with internal controls for contract review, approval and signature. Hold executive accountability for contract yield and reimbursement performance; direct reimbursement modeling, rate benchmarking and price transparency analyses that inform negotiation strategy, market entry and executive decision-making. Advise HOPCo executive leadership, market leadership and physician partners on payer, network and reimbursement strategy for new and existing markets, acquisitions, de novo sites and new service lines. Lead the organization’s value-based care glidepath with payers, evaluating and structuring bundled payment, shared savings and other alternative payment models appropriate to MSK care. Develop reimbursement strategy specific to MSK and orthopedic care, including site-of-service migration to ambulatory surgery centers, surgical case rates and bundles, implant and device carve-outs, imaging, therapy and DME fee schedules, and workers’ compensation and network participation strategy. Own executive-level payer relationships and governance, including Joint Operating Committees (JOCs), payer scorecards and escalation of systemic payment, policy, enrollment and network issues to resolution. Partner with Revenue Cycle leadership to ensure contracts are accurately loaded and contracted rates are realized through expected reimbursement, payment variance and underpayment recovery processes. Maintain disciplined contract lifecycle management, including a centralized contract repository, renewal, escalator and termination-notice tracking, amendments and fee schedule maintenance, so no renewal or rate opportunity is missed. Anticipate market, regulatory and payer trends and translate them into strategy, risk mitigation and recommendations for executive leadership; ensure compliance across all contractual and business relationships.Payer Enrollment & Credentialing Own enterprise payer enrollment and credentialing for all providers and locations, ensuring every physician, advanced practice provider, therapist and facility (ambulatory surgery centers, imaging, physical/occupational therapy and DME) is enrolled, effective and billable with every contracted payer. Oversee initial payer enrollment, re-credentialing/re-enrollment and revalidation across commercial, Medicare Advantage, Medicare (PECOS), Medicaid, Medicaid managed care, workers’ compensation and other government payers, at both the group and individual provider level. Ensure provider profiles are complete and current, including CAQH ProView attestation and payer authorization, licenses, DEA, board certification, malpractice and other expirables, so enrollment and re-credentialing are never delayed. Maintain accurate NPI/TIN, location, specialty and reassignment linkages to payer contracts; manage payer roster submissions, provider adds/terms/changes and directory accuracy so provider data matches what is loaded with each payer. Pursue and maintain delegated credentialing and roster-based enrollment agreements with payers where advantageous to shorten enrollment timelines; manage delegation requirements and payer audits. Integrate payer enrollment with physician recruiting, onboarding, acquisitions/affiliations and new location openings, using start-date-driven timelines and readiness checkpoints so new providers and sites are billable on day one. Reduce enrollment turnaround time, time-to-bill and enrollment-related denials and revenue leakage; partner with Revenue Cycle on claim holds, effective and retro-effective dates, and recovery of enrollment-related write-offs.Systems, Vendor Management & Operating Model Own the payer enrollment/credentialing, provider data management and contract management systems and integrations; lead system selection, implementation, optimization and automation, including workflow, tracking, reporting and emerging AI-enabled tools. Select, contract and manage outsourced payer enrollment, credentialing, contract modeling and other vendors; establish service level agreements (SLAs), KPIs, quality audits and governance cadence and hold vendors accountable for performance, accuracy and cost. Evaluate in-house, outsourced and hybrid operating models; develop cost-effective, scalable staffing and productivity models and benchmarks that support growth while controlling cost-to-serve.Process Improvement, Root Cause Analysis & Performance Reporting Champion enterprise-wide process improvement and operational transformation across contracting, credentialing and enrollment using Lean, Six Sigma or similar methodologies; standardize policies, procedures and work standards across markets. Conduct root cause analysis (RCA) on enrollment delays, enrollment-related denials, contract loading errors, underpayments and payer escalations; implement corrective action plans and sustain results through ongoing monitoring. Establish and maintain dashboards and KPIs (e.g., enrollment turnaround time, enrollment backlog by payer, time-to-bill, enrollment-related denials, contract yield and payment variance) to drive accountability and decision-making. Customer Service orientation- Provider Relations, Executive Communication & Cross-Functional Collaboration Lead with a customer service orientation; serve as the executive point of accountability for provider relations related to contracting and enrollment, setting service standards and response expectations for physicians, providers and practice leaders, and delivering clear, proactive communication on status, requirements, payer changes and expectations. Prepare and deliver executive report-outs to HOPCo executive leadership, market leadership and boards/partners on contracting performance, payer enrollment status, risks, financial impact and strategic recommendations. Build strong connection and collaboration across the organization, partnering with Revenue Cycle, Operations, Finance, Practice Leadership, Recruiting/Onboarding, Compliance, Legal and IT to align priorities and deliver shared outcomes. Leadership & Team Development Build, lead and retain high performing teams; set vision, goals and performance expectations, and foster a culture of accountability, service, engagement and continuous improvement. Drive leadership development, coaching and succession planning for directors, managers and emerging leaders; build cross-training and bench strength to support growth and continuity. Own the department operating budget, staffing plan and vendor spend; deliver against financial targets and demonstrate return on investment for technology, staffing and vendor decisions. Lead enterprise strategic initiatives that strengthen contracting, enrollment and value-based care infrastructure, scalability and profitability. Other duties and responsibilities as assigned. KEY OUTCOMES & MEASURES OF SUCCESS A multi-year payer strategy and negotiation calendar, prioritized by financial impact, adopted by executive leadership. Measurable improvement in contract yield and reimbursement against baseline, with contracted rates accurately loaded and realized. New providers and locations enrolled and billable by start date, with reduced enrollment turnaround time, claim holds and enrollment-related denials. Vendors and systems governed to clear SLAs and KPIs, with lower cost-to-serve as the organization grows. Executive leadership, market leaders and physicians receive clear, timely reporting and a consistently high level of service. An engaged, high performing team with strong bench strength and succession in place for key roles. The job holder must demonstrate current competencies for job position. EDUCATION Bachelor’s Degree in Business, Finance, Healthcare Administration or related field required; Master’s degree (MBA, MHA or related) preferred. Credentialing/enrollment or revenue cycle certification (e.g., NAMSS CPCS, HFMA CRCR) preferred. EXPERIENCE 10+ years of progressive leadership in payer contracting, managed care, payer enrollment and/or revenue cycle, including 5+ years in a senior leadership role (Director level or above) within a multi-site, multi-state physician group, MSO, health system or ASC environment. Proven track record personally leading complex professional and facility (including ASC) negotiations with national and regional payers and delivering measurable improvement in reimbursement and contract yield. Demonstrated experience leading payer enrollment and credentialing operations at scale, including CAQH, PECOS, Medicare/Medicaid enrollment and revalidation, commercial payer enrollment and roster management. Proven success selecting, implementing and managing enrollment/provider data systems and outsourced vendors through SLAs and performance metrics. Track record of leading enterprise-wide process improvement and operational transformation with measurable financial and operational results. Experience building and developing high performing, multi-level teams and presenting to C-suite, board and physician stakeholders. Orthopedic, MSK, ambulatory surgery or multi-specialty physician group experience strongly preferred; experience in a high-growth, multi-market, MSO or private equity-backed environment preferred. REQUIREMENTS Expertise in managed care contracting, reimbursement methodologies, contract modeling and medical cost trend analysis, including analysis of physician and facility contracts, utilization and costs. Working knowledge of CMS and state Medicaid enrollment and revalidation requirements, commercial payer credentialing requirements and delegated credentialing standards (e.g., NCQA). Experience with contract modeling, payer enrollment and provider data management platforms, CAQH ProView, PECOS, Medicaid and payer portals, and practice management/EHR systems (e.g., Epic, athenahealth, NextGen). Lean, Six Sigma or equivalent process improvement experience; certification preferred. Ability to travel to markets, payer meetings and corporate offices as needed. KNOWLEDGE Payer reimbursement methodologies, managed care contracting and value-based payment models. MSK and orthopedic reimbursement, including ASC, implants, surgical bundles and workers’ compensation. Credentialing, Payer enrollment, re-credentialing and revalidation requirements and timelines. Provider data management, roster and directory requirements. Revenue cycle operations and the impact of contracting and enrollment on denials, cash and time-to-bill. Healthcare market dynamics, payer landscape and regulatory/compliance requirements. SKILLS Proven people leadership; builds, inspires and retains high performing, multi-level teams with clear expectations and accountability. Commitment to leadership development, including coaching, mentoring and succession planning that grows future leaders. High emotional intelligence; self-aware, composed under pressure and skilled at reading people and situations, building trust and handling difficult conversations with empathy and professionalism. Collaborative relationship builder who earns credibility with physicians, payers, executives and frontline teams. Executive presence with exceptional written, verbal and presentation skills, including board- and C-suite-level communication. Expert negotiation skills with payers and vendors, including contract and SLA management. Strategic and financial acumen; ability to build and interpret reimbursement models and business cases. Advanced data analysis and reporting skills (Excel, BI/dashboard tools). ABILITIES Ability to operate as both strategist and hands-on operator, setting strategy and translating it into executable plans, measurable goals and results. Ability to lead through influence, build trust with physicians, payers and executives, and drive alignment across a matrix organization. Ability to translate complex contracting, enrollment and financial data into clear executive-level insights and recommendations. Ability to make sound decisions in ambiguous situations and to prioritize competing demands across multiple markets. Ability to manage vendor partners to contracted performance standards and hold teams accountable for results. Ability to lead organizational change and build scalable infrastructure in a high-growth environment. ENVIRONMENTAL WORKING CONDITIONS Normal office environment or Remote. Some travel may be required ORGANIZATIONAL REQUIREMENTS HOPCo Mission, Vision and Values must be acknowledged and adhered to OSHA Requirements and training to include: *Safety Training This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.