Director of Payor Contracting

Job Description

Job Description

JOB TITLE: Director of Payor Contracting 
FLSA STATUS (Exempt/Non-Exempt): Exempt 
SUPERVISION RECEIVED: Reports to Chief Executive Officer 
SUPERVISION EXERCISED: Payor Contracting and Reimbursement Staff 

GENERAL STATEMENT OF DUTIES  

Responsible for leading and managing Premier and Philadelphia Hand to Shoulder payor contracting strategy and contract portfolio across commercial, Medicare Advantage, Managed Medicaid, workers' compensation, auto, and other applicable payor arrangements. Leads contract negotiations, develops reimbursement strategies, manages the full contract lifecycle, evaluates financial and operational performance of payor agreements, and ensures executed contractual rates and terms are appropriately implemented and monitored. Partners closely with Revenue Cycle Management, Finance, Credentialing, Quality, Operations, physicians, and executive leadership to optimize reimbursement, identify and mitigate contractual risk, support value-based care arrangements, and advance the organization's strategic and financial objectives. 

ESSENTIAL FUNCTIONS  

• Leads payor contracting strategy and negotiations across commercial, Medicare Advantage, Managed Medicaid, workers' compensation, auto, direct-to-employer, and other applicable agreements.  

• Serves as the lead negotiator for major payor agreements and develops negotiation objectives and strategies for leadership approval.  

• Develops financial and reimbursement analyses to support contract negotiations, including market benchmarking, cost-to-serve analysis, and code-level modeling of surgical, non-surgical, imaging, ancillary, and advanced practice provider reimbursement.  

• Negotiates and structures multi-year reimbursement arrangements, percent-of-CMS fee schedules, surgical carve-outs, escalator provisions, case rates, bundled payments, percent-of-charge arrangements, and other reimbursement methodologies.  

• Evaluates proposed contract terms and reimbursement changes to determine financial, operational, and strategic impact to Premier and Philadelphia Hand to Shoulder. 

• Develops and maintains senior-level relationships with payor network, contracting, and medical leadership.  

• Leads payor escalations, contractual disputes, and termination scenarios and coordinates single-case agreements for non-contracted services as appropriate.  

• Presents contracting strategies, financial analyses, recommendations, and negotiation outcomes to executive leadership and other applicable governing bodies.  

• Owns and maintains the organization's payor contract system of record, including executed agreements, amendments, exhibits, fee schedules, and related documentation.  

• Establishes and maintains accurate contract renewal, expiration, and notice calendars to ensure contractual deadlines are identified and managed proactively.  

• Reviews and manages key contractual provisions, including payment-policy-change provisions, notice and termination requirements, authorization requirements, reimbursement methodologies, and other material contract terms.  

• Ensures executed agreements and amendments are appropriately documented, communicated, and operationalized across applicable departments.  

• Leads or participates in joint operating committee meetings with major payors and maintains appropriate issue logs, action items, and resolution tracking.  

• Partners with Revenue Cycle Management, Credentialing, Finance, and other departments through established contracting and payor governance processes.  

• Evaluates the financial impact of payor policy and reimbursement changes, including multiple procedure payment reductions, site-of-service changes, coverage policies, and other reimbursement modifications.  

• Determines whether payor policy or reimbursement changes require contractual remedies, escalation, renegotiation, or incorporation into future contracting strategies.  

• Partners with Revenue Cycle Management to validate that contracted reimbursement rates and terms are accurately reflected in actual payments.  

• Develops processes to identify expected-versus-actual reimbursement variances, underpayments, and other payor performance issues.  

• Partners with Revenue Cycle Management to facilitate resolution and recovery of identified contractual underpayments and incorporates identified trends into future negotiations.  

• Oversees and/or validates the accurate implementation of contracted fee schedules and allowable amounts within applicable systems, including modifier logic, advanced practice provider reimbursement, payor mapping, DME, and ancillary services.  

• Partners with Finance to develop payor contracting revenue-impact models and supports annual budgeting and forecasting activities.  

• Develops and maintains reporting regarding payor performance, reimbursement trends, contract opportunities, renewal activity, and portfolio risk for executive leadership.  

• Manages value-based and alternative payment arrangements, including episode-of-care and condition-focused programs.  

• Reviews and manages contractual requirements associated with attribution methodologies, benchmarks, quality measures, episode rules, settlements, and reconciliation.  

• Reviews value-based care settlement and quality results and challenges or escalates outcomes when supported by contractual terms.  

• Evaluates potential shared-savings, bundled payment, downside-risk, clinically integrated network, PHO, and other value-based arrangements.  

• Evaluates direct-to-employer contracting opportunities and other alternative contracting models based on financial, strategic, and operational considerations.  

• Partners with Quality and clinical leadership regarding quality measures and performance requirements associated with value-based contracts.  

• Leads and develops payor contracting and reimbursement staff, including hiring, training, performance management, coaching, workload management, and professional development.  

• Establishes standardized contracting processes, documentation, analytical tools, and workflows to ensure institutional knowledge is appropriately maintained.  

• Collaborates closely with Revenue Cycle Management, Credentialing, Finance, Quality, Operations, physicians/providers, and executive leadership.  

• Maintains confidentiality of contractual terms, reimbursement information, financial information, and other sensitive organizational information.  

• Participates in administrative meetings, committees, strategic initiatives, and special projects as requested.  

• Performs other duties as assigned.  

EDUCATION  

• Bachelor's degree in Business Administration, Healthcare Administration, Finance, Accounting, or a related field required.  

• Master's degree in Healthcare Administration, Business Administration, Finance, or a related field preferred.  

EXPERIENCE  

• Minimum of seven (7) years of progressive experience in healthcare payor contracting, managed care contracting, reimbursement, or a related field.  

• Demonstrated experience serving as the lead negotiator for major commercial payor agreements required.  

• Minimum of three (3) years of leadership or staff management experience.  

• Experience with physician and ambulatory reimbursement methodologies required.  

• Experience developing and analyzing financial models to support contract negotiations and reimbursement strategies required.  

• Experience with Medicare, Medicare Advantage, Medicaid, and commercial payor reimbursement required.  

• Experience in orthopaedics, musculoskeletal care, specialty physician practices, or ambulatory surgery center contracting strongly preferred.  

• Experience with value-based care, bundled payments, shared savings, or other alternative payment arrangements preferred.  

• Experience with payors in the Greater Philadelphia, Delaware, and/or South Jersey markets preferred.  

KNOWLEDGE  

• Advanced knowledge of healthcare payor contracting and negotiation strategies.  

• Knowledge of physician and ambulatory reimbursement methodologies, including percent-of-CMS fee schedules, surgical carve-outs, multiple procedure payment reductions, advanced practice provider differentials, case rates, bundled payments, and other reimbursement structures.  

• Working knowledge of CPT, HCPCS, modifiers, and other reimbursement methodologies necessary to evaluate physician and ancillary reimbursement.