Contracting & Payor Relations Director in Waltham, MA at Vaco

Date Posted: 6/23/2022

Job Snapshot

Job Description

Our organization is currently seeking Contracting and Payor Relations Director.

The Contracting and Payor Relations Director oversees a team of credentialing and payor contracting specialists to ensure that credentialing practices meet the needs of patients, facilities, payors, the market, state regulations and NCQA, Medicare/Medicaid, URAC, and/or Joint Commission credentialing standards.

The role is primarily responsible for creating and assisting with the development and implementation of supporting policies and procedures and workflows; handling payor contract management to maximize net operating margins and ensure market competitiveness; managing and monitoring the overall Credentialing Plan; evaluating the effectiveness of processes and procedures to support the plan; ensuring the organization is compliant with various credentialing requirements, as appliable; and maintaining payor rate sheet information and ensuring proper updates are distributed and/or uploaded.

QDW experience is strongly preferred.

MAJOR DUTIES AND RESPONSIBILITIES

  • Establish and implement strategic goals to align with department and corporate goals and objectives
  • Oversee the utilization and continuous improvement of the financial reports and analytics used for contract management
  • Serve as the organization's contact for payor contracting functions
  • Support resolution of payor contractual issues pertaining to contract interpretation and coding with payors in conjunction with revenue cycle staff
  • Assess payor contracting requirements and standards as they relate to industry/regulatory issues and market implications
  • Recommend and implement necessary improvements and revisions to contracting requirements and standards
  • Lead the development and testing of a contract pricing model and responsible for all activities related to the modeling of contract proposals that maximize net operating margins and ensure market competitiveness
  • Ensure that payor fee schedules are updated on a regular basis and are uploaded/assigned in QDW appropriately
  • Negotiate better payor fee schedule rates as the organization gains leverage through growth
  • Evaluate and update internal UCRs on a regular basis to ensuring that billing practices are positioned for maximum revenue
  • Evaluate charge integrity periodically by performing an analysis of charges and reimbursement for common procedures
  • Manage and monitor the overall credentialing plan, operations, and needs for compliance. Make any necessary changes.
  • Maintain up-to-date credentials for each licensed provider, including verification through primary and secondary sources, records, and relay credentialing information to relevant personal as needed
  • Keep accurate records of provider licensure/ certification renewals
  • Coordinate provider enrollments in all commercial, state, and federal insurance programs. Correspond with and provide updates to insurances.
  • Partner with multi-functional team of business leaders on day-to-day operations
  • Maintain knowledge of all state regulatory and accrediting body standards and maintain compliance
  • Oversee and/or manage Delegated Agreements and all audit and reporting needs associated with each
  • Participate in payor, state, and/or regulatory body interviews/presentations in discussions pertaining to credentialing
  • Provide on-going opportunity and challenge for staff development
  • Conduct regular meetings with direct reports and credentialing team to ensure that they are well informed of company goals and objectives, to set priorities, and to discuss progress towards goals
  • Develop mechanisms for regular on-going feedback on areas of development and/or accomplishments
  • Manage contracting and credentialing budget, as well as staffing needs

MINOR DUTIES AND RESPONSIBILITIES

  • Participate in other revenue cycle meetings, as necessary
  • Perform other duties as required or requested by leadership

PREFERRED QUALIFICATIONS

  • Bachelor's degree in a relevant subject
  • 2-3 years of dental experience
  • 5-7 years of credentialing experience minimum
  • Knowledge of credentialing software preferred
  • Working knowledge of NCQA and URAC Credentialing Standards
  • Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, government regulations, standardized instructions, short correspondence, and memos
  • Must be able to review and make necessary revisions in credentialing delegation agreements with external payor partners
  • 2+ years of supervisory experience

SKILLS AND ABILITIES

  • Excellent attention to detail
  • Self-directed, organizes and prioritizes work, and manages multiple tasks and assignments
  • Ability to work independently within guidelines and company policies
  • Manages time well and performs assigned duties with attention detail, accuracy, and follow-through with minimal supervision
  • Strong analytical and problem-solving skills with ability to identify trends, define problems, develop solutions, and execute strategies
  • Superior skills using Microsoft applications including Outlook, Teams, Word, Excel, and PowerPoint
  • Ability to supervise, train, and transfer job knowledge to colleagues
  • Strong verbal and written communication skills with ability to provide written communication/education to revenue cycle team members
  • Excellent interpersonal skills and experience interacting with clinical and financial personnel in a fast-paced, multi-disciplinary, team environment
  • Interacts with confidential information in a professional manner
  • Must be able to make independent decisions

Work environment

  • Up to 25% travel as needed for group RCM activities