Director Managed Care & Payment Integrity

Job Description

Job Description

Responsibilities

Norman Regional Health System (NRHS) is seeking a Managed Care leader to focus on managed care payer negotiations and payer contracting. This leader will serve as the organization’s internal owner of payer strategy across the Hospital (HB), Professional (PB), and Ambulatory Surgery Center (ASC) enterprises.

The Director will report to the Administrative Director of Revenue Cycle Management & Managed Care and will co-lead current and future contract negotiations, drive net-revenue reimbursement improvement, and build a disciplined payment integrity function that identifies and recovers underpayments, validates expected reimbursement, escalates systemic payer issues, and prevents avoidable denials.

Consistent with this reporting model, this Leader will be fully responsible for the multiple aspects of Managed Care and Payment Integrity, including charge description master (CDM), charge integrity, revenue integrity, vendor-related staffing relationships, and payer strategy.

The ideal candidate will bring significant, hands-on experience in both payer negotiations and payer contracting, complemented by depth in reimbursement analytics, payer escalation, denials prevention, vendor governance, and cross-functional operating model design. Experience across all three settings — HB, PB, and ASC — is highly valued, as is prior experience in the Oklahoma payer market.

Key Responsibilities

• Payer Negotiations & Contracting
  • Lead and directly execute managed care contract negotiations across commercial, government, and third-party payers, spanning HB, PB, and ASC agreements.
  • Own the end-to-end contracting lifecycle — strategy, rate modeling, term development, redlines, execution, and renewal — driving alignment of disparate agreements toward consistent terms and renewal cycles.
  • Develop payer-specific negotiation strategies and rate floors benchmarked to market (e.g., Medicare percentages and percentile positioning) to secure defensible, market-aligned reimbursement.
  • Serve as NRHS’s primary internal point of contact for payer relationships and external contracting partners, coordinating closely with executive leadership, PFS, and clinical stakeholders.
• Net-Revenue Reimbursement & Payment Integrity
  • Protect and grow net revenue by analyzing reimbursement performance, modeling contract terms versus expected payment, and identifying gaps at the payer, service-line, and setting level.
  • Build and lead a payment integrity discipline that detects and recovers underpayments, validates expected reimbursement, and identifies payment variances across payer contracts, charge integrity, and revenue integrity workflows.
  • Establish routine monitoring of contractual adjustments and write-offs to surface hidden or miscoded revenue leakage.
• Payer Escalation & Denials Prevention
  • Own payer escalation, driving structured monthly claims/issue forums with turnaround standards and holding payers accountable to contractual and administrative commitments.
  • Partner with PFS, Coding/CDI, Revenue Integrity, and Utilization Review to drive denials prevention — addressing authorization, medical necessity, COB/eligibility, and timely-filing root causes upstream.
  • Translate denial and underpayment trends into contract language, remediation plans, and settlement positions during negotiations.
• Charge Description Master (CDM) & Charge Integrity
  • Support governance of the Charge Description Master (CDM), ensuring accurate, compliant, and up-to-date charge codes, pricing, and CPT/HCPCS mapping across HB, PB, and ASC.
  • Assist charge integrity reviews to identify missing, duplicate, or non-compliant charges and to align charging with contract terms and reimbursement expectations.
  • Coordinate CDM updates with clinical, coding, and finance stakeholders, and manage supporting chargemaster, pharmacy pricing, and charge integrity tools.
• Revenue Integrity
  • Support the revenue integrity function, connecting contracting, CDM, coding, and denials/underpayment data into a closed-loop process that protects expected reimbursement.
  • Perform under- and over-payment audits, establish and monitor key revenue-integrity metrics, and drive root-cause remediation and system fixes.
  • Resolve the open managed care resource across payer contracting and revenue integrity questions by establishing a durable operating model and internal ownership.
• Vendor & Tool Oversight
  • Manage external vendors, staffing partners, and supporting platforms across payment integrity, out-of-network billing, chargemaster/pharmacy pricing, analytics, and revenue integrity; define scope, staffing model, performance expectations, implementation plans, and accountability for each relationship.
  • Evaluate build-vs-buy decisions and ensure vendors deliver measurable net-revenue impact rather than duplicating internal capabilities.
  • Clarify reporting, oversight, and day-to-day direction for vendor-related staffing relationships, ensuring external resources have defined deliverables, internal owners, escalation paths, and measurable accountability.
  • Coordinate shared or concurrent ownership of managed care, payment integrity, and revenue integrity functions - defining decision rights, operational hand-offs, and transition plans where responsibilities overlap.

Leadership & Collaboration

• Provide analysis, reporting and recommendations to the Executive Team and Senior Leadership, as well as supporting Executive Team decisions on negotiation strategy and go/no-go positions.
• Coordinate with external contracting resources, vendor-supported staffing, analytics partners, and current leadership while building internal ownership and institutional knowledge of NRHS payer strategy.
• Mentor and align revenue cycle stakeholders, establishing repeatable processes, SOPs, and governance for sustained payer performance.
• Establish governance for functions with concurrent ownership across Revenue Cycle, Managed Care, vendor partners - ensuring operational clarity, avoiding duplication, and maintaining accountability during times of transition.

Qualifications

• 5+ years progressive leadership experience in managed care payer negotiations and payer contracting, net-revenue reimbursement, payment integrity, payer escalation, underpayment recovery, and denials prevention required.
• Bachelor’s degree in Business, Healthcare Administration, Finance, or closely related field required.
• Demonstrable knowledge of and experience utilizing contract methodologies (DRG, case rates, per diems, fee schedules, percent-of-charge, carve-outs) and market benchmarking required.
• Demonstrable knowledge of and experience leading CDM, charge integrity, and revenue integrity operations required.
• Executive presence with the ability to synthesize complex analyses into clear recommendations for leadership and payers required.
• Experience across Hospital Billing (HB), Professional Billing (PB), and Ambulatory Surgery Center (ASC) reimbursement highly preferred.
• Experience partnering with revenue cycle vendors, analytics platforms, and legal/compliance on contract execution highly preferred.
• Demonstrable knowledge of and experience leading payment integrity, out-of-network billing, chargemaster, pharmacy pricing, analytics, and revenue cycle vendor platforms highly preferred.
• Experience managing vendor-related staffing relationships, external resources, and shared accountability models across revenue cycle, managed care, and ACO-adjacent functions highly preferred.
• Prior experience in the Oklahoma payer market and familiarity with regional commercial and government payers preferred.
• MBA or MHA preferred.