Director, Contracting and Payor Relations
Director, Contracting and Payor Relations, 100% Remote
We are currently working with a PE backed healthcare organization looking to add a Director, Contracting and Payor Relations to their team. This individual oversees a team of credentialing and payor contracting specialists to ensure that credentialing practices meet the needs of patients, facilities, payors, the market, state regulations and NCQA, Medicare/Medicaid, URAC, and/or Joint Commission credentialing standards.
The role is primarily responsible for creating and assisting with the development and implementation of supporting policies and procedures and workflows; handling payor contract management to maximize net operating margins and ensure market competitiveness; managing and monitoring the overall Credentialing Plan; evaluating the effectiveness of processes and procedures to support the plan; ensuring the organization is compliant with various credentialing requirements, as applicable; and maintaining payor rate sheet information and ensuring proper updates are distributed and/or uploaded.
Geography: 100% remote
MAJOR DUTIES AND RESPONSIBILITIES
- Establish and implement strategic goals to align with department and corporate goals and objectives
- Oversee the utilization and continuous improvement of the financial reports and analytics used for contract management
- Serve as the organization’s contact for payor contracting functions
- Support resolution of payor contractual issues pertaining to contract interpretation and coding with payors in conjunction with revenue cycle staff
- Assess payor contracting requirements and standards as they relate to industry/regulatory issues and market implications
- Recommend and implement necessary improvements and revisions to contracting requirements and standards
- Lead the development and testing of a contract pricing model and responsible for all activities related to the modeling of contract proposals that maximize net operating margins and ensure market competitiveness
- Ensure that payor fee schedules are updated on a regular basis and are uploaded/assigned in QDW appropriately
- Negotiate better payor fee schedule rates as the organization gains leverage through growth
- Evaluate and update internal UCRs on a regular basis to ensuring that billing practices are positioned for maximum revenue
- Evaluate charge integrity periodically by performing an analysis of charges and reimbursement for common procedures
- Manage and monitor the overall credentialing plan, operations, and needs for compliance. Make any necessary changes.
- Maintain up-to-date credentials for each licensed provider, including verification through primary and secondary sources, records, and relay credentialing information to relevant personal as needed
- Keep accurate records of provider licensure/ certification renewals
- Coordinate provider enrollments in all commercial, state, and federal insurance programs. Correspond with and provide updates to insurances.
- Partner with multi-functional team of business leaders on day-to-day operations
- Maintain knowledge of all state regulatory and accrediting body standards and maintain compliance
- Oversee and/or manage Delegated Agreements and all audit and reporting needs associated with each
- Participate in payor, state, and/or regulatory body interviews/presentations in discussions pertaining to credentialing
- Provide on-going opportunity and challenge for staff development
- Conduct regular meetings with direct reports and credentialing team to ensure that they are well informed of company goals and objectives, to set priorities, and to discuss progress towards goals
- Develop mechanisms for regular on-going feedback on areas of development and/or accomplishments
- Manage contracting and credentialing budget, as well as staffing needs
MINOR DUTIES AND RESPONSIBILITIES
- Participate in other revenue cycle meetings, as necessary
- Perform other duties as required or requested by leadership
- Bachelor’s degree in a relevant subject
- 5-7 years of credentialing experience minimum
- Knowledge of credentialing software preferred
- Working knowledge of NCQA and URAC Credentialing Standards
- Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, government regulations, standardized instructions, short correspondence, and memos
- Must be able to review and make necessary revisions in credentialing delegation agreements with external payor partners
- 2+ years of supervisory experience
SKILLS AND ABILITIES
- Excellent attention to detail
- Self-directed, organizes and prioritizes work, and manages multiple tasks and assignments
- Ability to work independently within guidelines and company policies
- Manages time well and performs assigned duties with attention detail, accuracy, and follow-through with minimal supervision
- Strong analytical and problem-solving skills with ability to identify trends, define problems, develop solutions, and execute strategies
- Superior skills using Microsoft applications including Outlook, Teams, Word, Excel, and PowerPoint
- Ability to supervise, train, and transfer job knowledge to colleagues
- Strong verbal and written communication skills with ability to provide written communication/education to revenue cycle team members
- Excellent interpersonal skills and experience interacting with clinical and financial personnel in a fast-paced, multi-disciplinary, team environment
- Interacts with confidential information in a professional manner
- Must be able to make independent decisions
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