Director of Managed Care - REMOTE

Pivotal Solutions; United States; On-site; USD 150,000 - 230,000; Full time

Job summary

Pivotal Solutions seeks a Director of Managed Care to lead the development, negotiation, and management of commercial, governmental, and value-based payer contracts. This role aims to optimize reimbursement, support strategy, and improve financial performance.

Reporting to the ACFO, the leader collaborates with Finance, Revenue Cycle, Legal, and executive leadership to advance payer strategies that enhance access, profitability, and long-term sustainability.

Qualifications

• Bachelor's Degree in Healthcare Administration, Finance, Business, Accounting, Economics or related field.
• MBA or MHA preferred.
• 7-10 years of progressive healthcare finance or managed care experience required.
• 3-5 years of payer contract negotiation experience required.

Responsibilities

• Provide executive leadership and strategic direction for managed care contractual relationships (commercial, Medicare, Medicaid, and other payer arrangements).
• Develop and execute managed care strategies aligned with organizational goals.
• Negotiate payer contractual agreements across commercial, Medicare Advantage, Medicaid Managed Care and value-based contracts.
• Review reimbursement methodologies (DRG, APC, fee schedule, per diem, capitation).
• Model reimbursement, margins, and financial impact with FP&A, Decision Support, and Reimbursement teams.
• Monitor payer performance, denials, underpayments, and contract compliance with Revenue Cycle.

Skills

Executive leadership

Payer strategy

Contract negotiation

Financial modeling

Cross-functional collaboration

Education

Bachelor's Degree in Healthcare Administration/Finance/Business/Accounting/Economics

MBA/MHA preferred

Job description

The Director of Managed Care is responsible for developing, negotiating, implementing, and managing commercial, governmental, and value-based payer contracts to optimize reimbursement, support organizational strategy, and improve financial performance. Reporting to the ACFO, this leader oversees the Managed Care department, partners with finance, revenue cycle, legal, and executive leadership, and develops payer strategies that enhance access, profitability, and long-term sustainability.

The Director supports organizational revenue goals through effective payer relationships, contractual agreements, and operational partnership. This role requires initiative, self-direction, leadership, and a team-oriented approach, with the ability to translate information into targeted action plans that meet evolving organizational needs. The Director must build collaborative relationships with internal stakeholders and external partners, influence decision-making outside direct reporting lines, and perform other duties as assigned.

Job Responsibility

• Provide executive leadership and strategic direction for managed care contractual relationships, including commercial, Medicare, Medicaid, and other payer arrangements.
• Develop and execute managed care strategies aligned with organizational goals.
• Negotiate payer contractual agreements, including commercial, Medicare Advantage, Medicaid Managed Care, employer, hospital, professional, ancillary, and value-based contracts, to meet organizational goals.
• Review reimbursement methodologies including DRG, APC, fee schedule, per diem, percent of charges, case rates, and capitation.
• Partner with FP&A, Decision Support, and Reimbursement teams to model reimbursement, margins, and financial impact.
• Partner with Revenue Cycle to monitor payer performance, denials, underpayments, contract compliance, and other contractual opportunities that improve revenue and reduce leakage.
• Monitor market trends and CMS regulations that may affect payer strategy, reimbursement, contract compliance, and provider enrollment operations.
• Responsible for building positive relationships with key health plans through regular communications/meetings to support the organizational goals.
• Communicate managed care changes, policy updates, and strategic direction across the organization to support alignment and timely implementation.

Education

• Bachelor's Degree - in Healthcare Administration, Finance, Business, Accounting, Economics, or related field
• MBA/MHA - Preferred

Work Experience

• 7-10 Years - progressive healthcare finance or managed care experience - Required
• 3-5 Years - payer contract negotiation experience - Required
• Experience with commercial, Medicare Advantage, and Medicaid Managed Care contracting
• Experience in 340b, DSH, Sole Community Hospital, Critical Access Hospital, rural health clinics, provider-based ad physician reimbursement