Director, Commercial Payer Contracting

The Director, Commercial Payer Contracting has oversight responsibility and overall accountability for contract negotiations with insurance companies, and TPA’s in his/her assigned market(s).     

Negotiates contracts with payers. Acts as consultant to other departments in the company regarding contracts negotiation and administration.  Connects operational and financial issues to contractual obligations for all functions as necessary.  Analyzes prospective agreements and recommends action. Maintains relationship with current payers to resolve problems.  Reviews key contract provisions with Center Ops team and obtains buy-in and approval of key provisions. Provides input and solutions for resolution of contractual issues. Incorporates information technology for effective contract management, data analysis, forecasting and reporting. Performs other duties as assigned.

The Contracting Department works collaboratively with Payer Relations in developing contracting strategy and communication materials that are in-line with Company goals.  Responsible for working collaboratively with internal (e.g., Payer Relations, Legal, Operations) and external constituencies in communicating the scope of services that are available.  Role will require intensive service in each market through introductions with various payers and contract negotiations.  Expected to take a minimum of three days a week in each market for a minimum of first four months of contract negotiation

• Identifies, assists in development, manages, monitors and executes contracting strategy in each assigned market.


• Develops multi-center and regional payer contracting strategy with Payer Relations and other members of the Reimbursement team where appropriate and supports any national contracting efforts that may be developed.


• Develops model individual patient contracts (PSA) for out of network patients and is responsible for negotiation management and coordination with center staff related to contracting individual out of network patient contracts.


• Reviews and negotiates contract language provisions with payers and assists with Medicare/Medicaid.


• Negotiates effective and competitive contractual relationships in accordance with company strategies.


• Assists in development and implementation of appropriate reimbursement methodologies and contractual strategies with Senior Management.


• Coordinates contract implementation and education.


• Enhances quality and cost effectiveness of contracted network of health plans.


• Assists in pre and post contract implementation audits to ensure provisions meet the intent of the contract.


• Coordinates issue resolution and complex trouble shooting for providers.


• Develops and uses management tools to monitor and report progress of contract negotiation process.


• Develops and uses appropriate tools and database to report on existing contract arrangements, terms and effective dates with appropriate center teams.


• Initiates, manages and coordinates payer credentialing process.


• Develops summary matrix for senior management deal approval and contract loading.


• Responsible for working in tandem with Medical Director or designee and Center Executive Director as necessary to make introductions of proton treatment and coverage policy and appropriate reimbursement with payers, Medicare and Medicaid.


• Responsible for working with the Medical Director or designee and Payer Relations in the development and maintenance of proton coverage policy to be recommended to payers, Medicare and Medicaid.


• Responsible for establishing and maintaining relationships with Network Management Teams of payers, Medicare and Medicaid as well as necessary supporting constituents such as Medical Societies and CAC representatives.

 REQUIREMENTS

• Bachelor’s Degree in Business or Health Administration, or related field.


• MBA or Masters Degree preferred.


• Minimum of five years of contract negotiation experience in health care contracting or a managed care environment. 


• Provider-based experience, particularly in the cancer field is preferable but not required.


• Background must include contractual, administrative, health insurance and operational issue resolution related to commercial insurance organizations. 


• Experience in Health Plan credentialing work flows and process requirements.