Director, Payor Relations and Regulatory Affairs

The Opportunity

Our client is in search of a Director, Payor Relations and Regulatory Affairs. In this role you will be accountable for developing strategies and driving ongoing activities that maintain and expand payor coverage while ensuring the business remains compliant with standards required by The Joint Commission, state agencies, and CMS (Medicare/Medicaid).

About the Role

These activities include leading the development, implementation, and monitoring of processes related to commercial payor contracting, state licensing, and CMS enrollments. These processes span across all lines of business..

Responsibilities

• Directly hires, develops, and drives engagement for team members across Payor Relations and Regulatory departments
• Oversees 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
• Oversees 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
• Maintains 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
• Develops, maintains, and presents to leadership the KPIs/metrics related to areas of responsibility
• Contributes 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.

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.

Required Skills

• Master’s Degree in related field
• 5+ years experience in payor contracting within the DME/IDTF provider space
• 5+ years experience working directly with CMS (Medicare/Medicaid), The Joint Commission, and state licensing agencies