Senior Director, Payer Strategy and Relations

4 months ago

Teaneck, United States Comprehensive Cancer Centers of Nevada Full time
Overview

SCOPE:

Strategic: Leads all strategic development of third party payer strategies for Regional Cancer Care Associates (RCCA). Directs the formulation and execution of all managed care initiatives and strategies that will maximize opportunities with third party payers and provider partners including hospitals and PCP networks and employers statewide. Oversees managed care related policies, procedures and processes in support of strategic objectives. Develops and executes practice strategic planning and both long and short term goals to position Regional Cancer Care Associates optimally within the third party payer environment and local hospital/provider market.

Prepares forecasts and advises senior management both within RCCA Practice Leadership on all matters concerning net revenues in the areas of Commercial Managed Care, Medicaid and Medicare. Develops and maintains payer relationships and advocates for the community-based oncology agenda with payers locally, identifying opportunities for enhanced relationships, reimbursement, referrals and a growing market presence. Overall, responsible for directing all contract negotiations and strategies to support revenue growth for Regional Cancer Care Associates.

Operational: Leads all strategies and negotiations to support alternative payment models with a focus on including novel payment models such as value-based reimbursement methodologies (i.e., case rate development, integrated networks, contract capitation, total cost of care initiatives and shared savings models) and has a firm grasp on the analytics/practice impacts that support such payment models. Serves as "expert" advisor to management team regarding maximizing revenue from managed care products and Medicare and Medicaid programs. Develops and makes recommendations regarding changes needed to enhance and optimize physician income and overall practice revenues. Ownership of key relationships between Regional Cancer Care Associates and health system partners to drive coordinated, high-quality care.

Program Outcomes: Collaborates with Quality team to develop alternative payment models and ensure delivery of compelling performance which results in gain share and optimization of quality measures. This includes incorporation of practice reporting, outcomes measures, etc. developed and used in support of such practice initiatives. Includes leadership and a focus to support risk-based contracts, claims studies, actuarial evaluations and episodic payments where gain share (or upside), steerage and other upside to the practice are included.

Organizational Responsibilities: Creates a shared vision and demonstrates the ability to clearly articulate the organization's desired position, creates a common goal for unity among groups with diverse interests and beliefs, clearly communicates the organization's mission, strategies, goals and priorities, defines team members' roles and responsibilities, seeks input and buy-in from team members and establishes alignment throughout the organization. Supports and adheres to Compliance Program, including the Code of Ethics and Business Standards.

Combines judgment, extensive experience and business and industry knowledge to make sound decisions.

Responsibilities

ESSENTIAL DUTIES AND RESPONSIBILITIES:
  • Plans, develops, directs, coordinates and monitors all managed care activities to successfully bring to market new products, methodologies, and strategies and to negotiate compelling contracts with both payers and providers (where appropriate).
  • Works with RCCA operations, finance, Managed Care team and the pharmacy team, directs and advises on strategies and solutions, and sets benchmarks to ensure that contracts negotiated in accordance with budgeted objectives to obtain maximum profitability and volume in relation to pre-set standards and specific trends within the industry.
  • Evaluates practice trends and variances for planning and provides information to senior management and field. Communicates and educates all internal customers as to the prudent and most effective manner with which to deal with payers.
  • Develops and recommends payer pricing, contracting and operational strategies to optimize the long-term financial profitability of the practices and the company. Evaluates opportunities to take financial risk and looks proactively to ensure a longer term, compelling strategy to ensure a growing referral base, market differentiation and practice growth.
  • In coordination with the revenue cycle leadership, evaluates, sources, designs, recommends and monitors the execution and effectiveness of policy, procedure and processes designed to ensure timely and accurate reimbursement from payers.
  • Takes responsibility for and coordinates the execution of all aspects of Regional Cancer Care Associates' tactical and strategic payer initiatives including responsibility for creating and maintaining positive external relationships with all relevant payers, providers, health systems and employers, where relevant.
  • Oversees legal and regulatory environment as well as serves as an "expert " resource related to legal and business review of all managed care contract documents, amendments, and correspondence.

OTHER KEY RESPONSIBILITIES
  • Coordinate activities, exchanges information and clarifies needs from a Managed Care perspective with marketing, business development, finance, revenue cycle management, pharmacy operations and the clinical team.
  • Serves as the Managed Care liaison/advocate for new practices that are added to Regional Cancer Care Associates.
  • Works with and coordinates local managed care initiatives with the Managed Care support staff.
  • Monitors markets, industries, and companies to maintain and update information base by participating in industry organizations including developing new contracts, knowledge and trends to cultivate new strategies.

Qualifications

MINIMUM QUALIFICATIONS:
  • Excellence in academic training at all levels. Master's degree required in Finance, Business, or Healthcare Administration
  • Minimum of ten years healthcare management experience in a managed care environment, including significant experience in commercial payer strategies, pricing, reimbursement and healthcare costing analysis.
  • Supplemental experience in strategy consulting in healthcare related fields or serving healthcare clients may be relevant. Comprehensive knowledge of healthcare planning, finance, marketing, reimbursement, and related activities.


PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 30 pounds. Requires vision and hearing corrected to normal ranges.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work is performed in an office environment or may be remote and requires significant interaction with managed care regional team as well as local managed care resources and Practice leadership teams and externally with clients and customers. Work will require local by automobile and attendance at national meetings, as needed.

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