Director Payor Relations
Gateway Recruiting, San Francisco, CA, United States
The Opportunity:
This Director, Payor Relations and Regulatory Affairs will be accountable to develop strategies and drive ongoing activities that maintain and expand payor coverage while ensuring ACH remains compliant standards required by The Joint Commission, state agencies, and CMS (Medicare/Medicaid). These activities include leading the development, implementation, and monitoring of processes related to commercial payor contracting, state licensing, and CMS enrollments.
Responsibilities: The following reflects essential functions for this job but does not restrict the tasks that may be assigned. Management may assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons.
Directly hire, develop, and drive engagement for team members across Payor Relations and Regulatory departments
Oversee essential activities and process improvement related to commercial payor contracting across all lines of business; specific contracting activities include, but are not limited to:
Contract redlining
Contract implementation
Contract monitoring
Contract management, including initial & ongoing credentialing
Payor escalation management, including payment discrepancy resolution
Oversee essential activities and process improvement related to regulatory affairs for ACH; specific contracting activities include, but are not limited to:
State licensing
Medicare and Medicaid enrollments
The Joint Commission Accreditation
Maintain governance processes to ensure alignment to contracting and regulatory business expectations with cross-functional stakeholders, including: finance, commercial operations, revenue cycle management, legal, and the office of ethics & compliance
Develop, maintain, and present to leadership the KPIs/metrics related to areas of responsibility
Contribute to business strategies related to commercial contracting, payor management, and regulatory compliance; examples include: patient access, pricing, payor management, Medicaid advocacy, state licensing applications, and accreditations.
Required Qualifications:
Bachelor’s Degree in a business discipline
10+ years relevant experience in payor contracting at a healthcare provider, payor, or network
5+ years directly interacting with regulatory agencies
Demonstrated ability to develop, improve, and monitor commercial contracting processes
Ability to work independently and managing competing priorities routinely.
Preferred Qualifications:
Master’s Degree in related field
5+ years of experience in payor contracting within the DME/IDTF provider space
5+ years of experience working directly with CMS (Medicare/Medicaid), The Joint Commission, and state licensing agencies
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Responsibilities: The following reflects essential functions for this job but does not restrict the tasks that may be assigned. Management may assign or reassign duties and responsibilities to this job at any time due to reasonable accommodation or other reasons.
Directly hire, develop, and drive engagement for team members across Payor Relations and Regulatory departments
Oversee essential activities and process improvement related to commercial payor contracting across all lines of business; specific contracting activities include, but are not limited to:
Contract redlining
Contract implementation
Contract monitoring
Contract management, including initial & ongoing credentialing
Payor escalation management, including payment discrepancy resolution
Oversee essential activities and process improvement related to regulatory affairs for ACH; specific contracting activities include, but are not limited to:
State licensing
Medicare and Medicaid enrollments
The Joint Commission Accreditation
Maintain governance processes to ensure alignment to contracting and regulatory business expectations with cross-functional stakeholders, including: finance, commercial operations, revenue cycle management, legal, and the office of ethics & compliance
Develop, maintain, and present to leadership the KPIs/metrics related to areas of responsibility
Contribute to business strategies related to commercial contracting, payor management, and regulatory compliance; examples include: patient access, pricing, payor management, Medicaid advocacy, state licensing applications, and accreditations.
Required Qualifications:
Bachelor’s Degree in a business discipline
10+ years relevant experience in payor contracting at a healthcare provider, payor, or network
5+ years directly interacting with regulatory agencies
Demonstrated ability to develop, improve, and monitor commercial contracting processes
Ability to work independently and managing competing priorities routinely.
Preferred Qualifications:
Master’s Degree in related field
5+ years of experience in payor contracting within the DME/IDTF provider space
5+ years of experience working directly with CMS (Medicare/Medicaid), The Joint Commission, and state licensing agencies
#J-18808-Ljbffr