United Digestive is seeking a Director, Payer Relations to join our growing team. The Director plays a pivotal role in our continued success and scaling, leading all aspects of UD’s efforts to build and strengthen partnerships with major commercial payors.
Critical Outcomes
Develop and implement metric-based, nationwide payer relations strategy for the organization
- Develop relationships with top commercial payer leadership including leading regular, strategic conversations about access, quality, and cost
- Devise annual strategic contracting plan across UD footprint; prioritize negotiations across states and service lines
- Secure consolidated, nationwide contracts, whenever possible
- Incorporate quality data to aid in increased reimbursement or increased volume capture
- Present and receive leadership approval for strategic contracting plan
Lead contract evaluation and strategy for United Digestive expansion in existing and new states
- Analyze current contracted rates to benchmarks and seek improved rates
- Review and codify new target contract language
- Quantify financial impact of TIN changes, if applicable
- Develop and implement strategic plan to consolidate and/or integrate TINs
- Lead contract negotiation efforts to secure new contracts and/or rate amendments
- Create data-based proposals for contract rate negotiations; analyze counter proposals
- Coordinate credentialing and enrollment needs with Vice President of RCM
- Align scheduling guidelines based on contract inventory by TIN
Maintain accurate contract and rate inventory to ensure appropriate payment is received and contracts are at top of market
- Maintain inventory of key contract terms and renewal dates
- Maintain database of payer contracted fee schedules and benchmarks
- Partner with RCM and payment review software to identify payment concerns; collaborate with RCM to address underpayments with payer representatives
- Utilize PowerBI and payment review software to track, measure and analyze payer reimbursements
- Provide notice to payers for contracted rate increases and monitor implementation of such
- Evaluate utilization of and set self-pay rate bundles across organization
Lead collaborative relationships across the organization and with external partners
- Be fully vested and versed in the organization’s business model
- Review and analyze Professional Service Agreements across the organization
- Establish regular cadence with CFO, Vice President of Finance, Vice President of RCM and other leaders to discuss revenue recognition, payor contracting, and coding reimbursement perspectives
- Partner with other peers and key business leaders to help them identify and access the data insights they need to drive informed decisions
- Coordinate contracting, scheduling guidelines and payment review analysis for partner- owned/managed endoscopy center IDs such as USPI and Northside Hospital
Monitor payer policy changes and communicate key insights across organization
- Monitor clinical guidelines, healthcare regulatory policies and payer policies
- Analyze potential or real impact on business
- Develop strategies to enhance revenue and mitigate risk as policies evolve
- Communicate current payer policy impact summaries to leadership and field, as appropriate
Core Leadership Traits & Competencies
Executive presence and entrepreneurship around the core Payer Relations functions:
- Possess strong ability to interact across key company leaders, external entities, and key contacts
- Possess compelling communication skills to present confidently to executives.
- Bring entrepreneurial thinking.
- Be in execute mode – confident enough to take steps to improve the program.
- Roll up your sleeves, get into the numbers, and be willing to do the work.
Demonstrate proactive inquisitiveness and business savvy:
- Identify the key value levers as well as their sensitivities to other operational factors and market dynamics.
- Proactively identify obstacles between the company’s current state and future state and determine strategies to close those gaps.
- Dig for business insights that are not readily available currently and transform the technology in order to acquire further insights needed.
- Proactively brief colleagues on your insights and suggest changes to current operations where appropriate.
- Respond thoughtfully and cogently to key stakeholders, including the CFO and CEO.
Be collaborative in assessing options but decisive when needed:
- Work in a collaborative manner. Proactively seek out others’ opinions before making decisions with strategic implications.
- Coordinate cross-functionally to ensure effective execution.
- Be willing to lead and make decisive day-to-day decisions.
- Be reliable. Once a decision is made, ensure follow-through.
Desired Experience
Must Haves:
- 5+ years in payer relations, preferably with physician services, hospital or top commercial payer
- Strong experience in analysis, strategy, simplification and presentation of complex data sets at the Board level
- Experience working in multi-site or national scale payer relations
- Experience in Value-Based Care
- Strong partnership with and knowledge of RCM functions including fee for service billing
Nice to Haves:
- Experience in Gastroenterology, Ambulatory Surgery, and multi-state provider practice
- Lean or Six-Sigma Certification
- Experience in private equity backed healthcare organizations
- Established relationships within third party payer organizations
