Senior Director, Payer Relations
Job Type
Full-time
Description

We have a hybrid work arrangement.


 EOE: race/color/religion/sex/sexual orientation/gender identity/national origin/disability/vet 


JOB SUMMARY: 


Coordinates with a network of hospital and health system managed care, revenue cycle, and compliance professionals. Provides in-depth research, support, education, and advocacy around issues of healthcare reimbursement and compliance, including managed care (commercial, Medicaid, and Medicare Advantage), TennCare, workers’ compensation, payment innovations, changes in methodologies, and program integrity. Utilizes data, when possible, to demonstrate impacts of payer issues. Assists in the creation of educational and professional development opportunities for member hospitals related to current and emerging topics in managed care, revenue cycle, and compliance. 


ESSENTIAL FUNCTIONS OF THE JOB:


1. Provide in-depth research, support, education, and advocacy for members around issues of healthcare finance and reimbursement. Serve as a resource and respond to member inquiries on these issues in a timely and effective manner.

  • Provide      a forum for addressing members’ issues with payers and represent THA      members around common administrative matters. Work with hospitals to      identify, research and then negotiate solutions to, or mitigate the impact      of, common issues that hospitals encounter with payers (commercial,      Medicaid, or Medicare Advantage). 
  • Communicate regularly with hospital members around      current developments impacting reimbursement, providing education on      changes as well as receiving input on their concerns.
  • Evaluate      and provide feedback on payer proposals and plans to implement policy changes      impacting hospital operations or payment; analyze potential impacts and educate      members.
  • Provide      input and make recommendations into the development of TennCare policy and      reimbursement issues. Provide      education and advocacy around transitions and programmatic changes within      the TennCare program as well as TennCare operational issues, reimbursement      methodologies, and benefit changes.
  • As needed,      work with the TennCare MCO Operations team and the TennCare Oversight      Division of the Tennessee Department of Commerce & Insurance      to address issues and concerns regarding the TennCare Managed Care      Organizations (MCOs).
  • As      needed, work with the Tennessee Department of Commerce and Insurance to      address issues and concerns regarding commercial payers.
  • Monitor      proposed state changes to workers’ compensation payment methodology, fee      schedule, and rules. Identify concerns, develop recommendations, and share      impacts with THA leadership.
  • Monitor      changes in the Medicare Advantage program and commercial payer policies and      as needed, communicate changes and potential impacts with members.
  • Work      with other states on national payer issues, including surveying members      and payer scorecards, develop policy responses to payers and participate      in meetings with state and national payers regarding administrative and      operational issues.
  • Participate      in CMS Region IV calls to stay abreast of Medicare and Medicare Advantage      issues impacting members. Advocate for      solutions to issues impacting Tennessee hospitals.
  • Assist      in the planning and execution of educational opportunities for members associated      with reimbursement and managed care best practices, payer updates, and      exchange plan offerings.
  • Assist      in the planning of the multi-state managed care conference.

2. Provide subject matter support for various THA workgroups.

  • Participate      as needed in Inpatient Rehab Facility (IRF), Long-term Acute Care Hospital      (LTACH), Home Health, Behavioral Health, and other workgroups as needed.
  • Assist      in the facilitation of the managed care, revenue cycle, and compliance      workgroups.

o Aid in the development of agendas based on current issues, trends, regulatory advisories, member feedback, etc.

o Help create presentations as needed for the workgroups to foster communication and discussion.

o Ensure compliance with all laws, especially paying close attention to federal antitrust regulations.

o Maintain notes from the workgroup meetings and share them with workgroup members.

o Follow up on and assist members in resolving issues as applicable.

3. Provide in-depth research, support, education and advocacy for members around healthcare compliance issues and program integrity. Provide a statewide focal point for compliance education and compliance officers. Respond to member queries on these issues.

  • Provide      in-depth research and assist in coordinating education on current topics      in healthcare compliance.
  • Monitor      and research proposed governmental program changes and make      recommendations based on knowledge of their impact on hospital operations.
  • Provide      forums for those responsible for compliance and program integrity in hospitals      to discuss issues. Assist in the      planning and execution of THA’s annual compliance conference and other compliance      education as needed.
  • Partner      with healthcare fraud enforcement agencies (including but not limited to      US Attorney offices, Medicaid program integrity and CMS Office of Inspector      General) to keep lines of communication open and to provide current      information to members.

4. Maintain payer scorecard system and inpatient rehabilitation facility (IRF) payer database. Review data for trends and make recommendations to address identified issues and ways to improve THA’s use of payer data. As applicable, respond to member inquiries regarding payer scorecard system or IRF payer database.

5. Review proposed state and federal legislation and assist in drafting talking points for the advocacy teams. Provide feedback about potential impacts to hospital finances and operations resulting from proposed bills and assist in gathering feedback from members, including the applicable workgroups, to assist with impact analyses.

6. Must have the ability to adapt to a changing work environment and meet challenges presented throughout the day.

7. Must be available for out-of-town travel approximately 10 percent of the time, be able to drive an automobile and maintain a valid driver’s license. Must travel both within and out of the state for various meetings as needed.

8. Must be available in the office during regular office hours unless job responsibilities require otherwise, or hybrid work arrangement is in place.

  

ORGANIZATIONAL STRUCTURE: (Positions reporting directly to this position.)

None


GUIDANCE & DIRECTION: (Policies, precedents or procedures that guide this work.)

1. Reimbursement and compliance rules (commercial or governmental) must be known, followed, and considered

Requirements

  

Educational and experience Requirements Needed to Perform the Duties of the Job:


1. Educational requirement:

          Bachelor’s degree in accounting, finance, or other related field required. 

2. Minimum of five years’ experience in health care required. Background experience and knowledge should include:

        -Detailed knowledge of hospital revenue cycle and/or managed care—commercial, Medicare Advantage, Medicaid, 

and workers’ compensation, including:

                Reimbursement methodologies

                Financial analysis 

                Legal/contractual issues

                Reimbursement audits

                Investigation and resolution of payment errors

                Operational issues

                Measuring contract performance

        -Hospital and/or health system operations experience desired

        -General knowledge of the following as it relates to hospitals:

                Accounting/auditing

                Billing and collections

                Healthcare compliance 

                Health information management

                Utilization management

                Quality & accrediting bodies

3. Experience with the following:

                Managing or conducting reimbursement analysis/negotiation

                Contractual language

                Operationalizing financial arrangements

                Identifying and resolving issues involving reimbursement, hospital operations, and healthcare compliance

                Building and managing relationships with managed care payers/outside entities


Skills Required to Perform the Duties of the Job:


1. In-depth understanding of hospital or healthcare operational, technical, regulatory, and contractual issues and procedures.

2. Must be analytical and able to ascertain and process facts related to a potential concern and use good judgment as to whether problems actually exist or need to be escalated.

3. Must have strong problem-solving skills and be able to find solutions through detailed research, strategic thinking, and effective communication.

4. Ability to understand both sides of a dispute and move toward resolution/mitigation of issue.

5. Ability to work constructively with payers and maintain positive working relationships while advocating for hospital members.

6. Must have excellent written and verbal communication skills.

7. Must have the ability to take complex issues and explain them in an appropriate manner based on the knowledge level of the audience.

8. Must be able to think through creative ways to solve problems. Must be able to navigate and negotiate complicated multi-faceted issues within complex relationships. Needs to be able to understand the interconnectedness of the healthcare finance environment.

9. Must be proficient in Microsoft Word, Outlook, Excel, PowerPoint, and Teams.

Salary Description
$115,000 - $125,000 annually