Region Director Payer Strategy

CommonSpirit Health; Rancho Cordova (CA); Remote; USD 120,000 - 180,000; Full time

Job summary

CommonSpirit Health seeks a Regional Director for Payer Strategy and Relationships in California. This remote role focuses on developing payer relationships, negotiating contracts, and ensuring optimal reimbursement strategies for managed care. Candidates should have extensive experience in the managed care industry and a strong background in negotiation and financial analysis.

Qualifications

• Minimum of five years in managed care with strategy responsibility.
• Four years of leadership experience required.
• Extensive knowledge of reimbursement methodologies.

Responsibilities

• Develop and maintain payer relationships and negotiation strategies.
• Participate in contract renewal planning and implementation.
• Support strategic objectives through engagement with local payers.

Skills

Negotiation skills

Financial analysis

Contract preparation

Problem assessment

Interpersonal skills

Education

Bachelor’s Degree or equivalent experience

Job description

The Regional Director, Payer Strategy and Relationships (PSR), is a remote position and is responsible for managed care policies, goals and objectives related to contract language and reimbursement (capitation, fee-for-service, and quality incentive programs), negotiation strategy, and payer relationships for all Physician Enterprise and hospital-based clinic physician entities across California. There are currently 12 Medical Groups with 160+ clinic sites and over 5,000 physicians in our medical networks. It is preferred that the candidate resides in the California market and must have extensive experience working with California health plans and IPAs. The Regional Director is primarily focused on payer relationships and health plan contracting for all managed care lines of business and collects and communicates Region-level insight and strategic knowledge to/from the PSR National Payer teams, Physician Enterprise, the PSR Growth & Innovation team, and other key departments across the enterprise. This position is essential to CommonSpirit Health’s financial performance, and has significant impact on the long-term strategic trajectory of the organization. This position secures optimal fee for service and value-based reimbursement, protects the interests of the owned and/or affiliated hospitals/ancillaries/professional provider entities in contract negotiations, and strengthens CommonSpirit Health’s relationships with payers.

Key Responsibilities

1. Participates in the development of regional strategy, relationships, and contracts with local and national payers to further drive a clear and effective negotiation strategy, reimbursement structure, contract renewal planning process, and contract implementation. Budgeted and forecasted performance and growth requirements as set forth by national and regional senior leaders are integral to these processes.

2. Gathers information and guidance from Regional PSR VP, ministry leaders, internal stakeholders, and financial analysis relative to the strategic, operational, financial needs and expectations of the CA Region related to the National Payers; proactively communicates with the PSR National Payer teams.

3. Establishes, builds, and maintains positive, strategic interactions and relationships with payers, employers, providers, and leaders across the ministry. Maintains relationships with National Payer contacts with offices in the region.

4. In collaboration with Regional Leadership and other PS&R Leadership, develops and executes communication plans and Payer Negotiation Outlines related to payer relationships, negotiations, organizational contractual obligations, and developments in the managed care marketplace including Fee For Service and Value-Based Agreements in support of CommonSpirit Health’s Healthier Communities strategy.

5. Makes independent decisions and/or exercises judgment based upon appropriate information and objectives. Comprehends and maintains highly detailed information. Accepts and carries out responsibility for direction, control, and planning.

6. Stays current with emerging payer trends, new reimbursement methodologies, state specific regulatory issues, plan benefits, payer activity, products and delivery channels including health insurance exchanges, market competition, etc.

7. Supports the strategic objectives of CommonSpirit Health’s IDNs, population health, and care management initiatives through directly engaging local payers and employer customers, including CSH employee health benefits.

8. Participates in and contributes to CommonSpirit Health’s PSR knowledge base through sharing best practices, developing contract performance goals, key metrics, new analytical tools, network development, reimbursement and language guidelines, revenue realization, and other applicable work streams.

9. Represents Physician Enterprise entities in Provider Excess bidding process with broker each year to analyze and establish appropriate coverage for each market population. This is done along with other Directors representing hospital interests.

10. Participates in the dispute resolution and denials processes with local payers if the materiality exceeds $1M. Participates in joint operating committees and denial committees for Physician Enterprise as needed.

11. Leads and organizes sub-projects necessary to support local and national payer negotiations and growth.

Qualifications

Education and Experience:

• Bachelor’s Degree – equivalent education and experience in payer strategy, managed care or provider network senior level role may be considered in lieu of degree

• Minimum of five (5) years of recent experience in the managed care industry with responsibility for strategy and negotiations.

• Minimum of four (4) years of leadership and supervisory experience

Required Minimum Knowledge, Skills, Abilities, Training

• Working knowledge of provider and payer industry.

• Strength in assessing problems and implementing solutions.

• Significant knowledge of contractual, administrative, health insurance and operational issues related to managed care organizations, physician groups, hospitals and health insurance benefit plan designs.

• Proven and extensive technical skills, negotiation skills, contract preparation and implementation, financial analysis and rate proposal development, and in-depth knowledge of various reimbursement methodologies for both fee for service and value-based contracts, including capitation and various incentive programs.

• Demonstrated ability to set and maintain multiple priorities in an environment with shifting priorities, while providing accurate deliverables in a timely fashion.

• Strength in self-motivation and ability to assume ownership of assignments and projects. Driven to succeed.

• Strong interpersonal, verbal, and writing skills in dealing with payers, guests and team members.