Dir. Payer Relations-Payor Contracting

Summary

Job Summary

The Director of Payer Relations is responsible for the strategic oversight and operational management of payer contracting, physician credentialing and enrollment, and payer performance optimization, including HEDIS-related initiatives. Ensures optimal reimbursement, regulatory compliance, and alignment with organizational financial and quality objectives.  Serves as the primary liaison between the organization and third-party payers, assisting with leading contract negotiations, resolving escalated payer issues, and driving performance improvement initiatives that impact revenue integrity, network participation, and value-based outcomes.

Minimum Job Requirements:

Work Experience:

Five years of experience in payer enrollment or credentialing within a hospital or healthcare system. Strong knowledge of CMS, Medicaid, and commercial payer requirements.  Knowledge of HEDIS measures, value-based care models, and quality performance programs.

Five years of management experience required.

License/Registration/Certification:

None

Education and Training:

Bachelor’s degree in healthcare administration, Business, or related field required.  Master’s degree preferred.

Skills:

1. Comprehensive knowledge of payer contracting, provider credentialing, and payer enrollment operations across Commercial, Medicare Advantage, Medicaid, and Managed Care.
2. Advanced knowledge of healthcare reimbursement methodologies, payment models, and contract structures.
3. Knowledge of federal and state regulations, CMS requirements, NCQA standards, Joint Commission standards, and payer‑specific credentialing requirements.
4. Knowledge of revenue cycle operations and the impact of provider enrollment and credentialing on billing and reimbursement.
5. Proficiency in credentialing and enrollment systems, payer portals, and Microsoft Office Suite.
6. Excellent leadership, communication, and organizational skills to effectively lead teams and engage executive stakeholders.
7. Skill in leading, developing, and managing multidisciplinary teams, including performance management, coaching, and staff development.
8. Skill in developing, negotiating, executing, and overseeing payer contracts and lifecycle management.
9. Strong analytical and problem-solving abilities, including contract modeling, reimbursement analysis, and payment variance evaluation.
10. Skill in developing and evaluating performance dashboards, KPIs, and executive‑level reporting related to payer and financial performance.
11. High attention to detail and a strong commitment to compliance, audit readiness, and documentation standards.
12. Ability to manage multiple priorities and deadlines in a fast‑paced hospital or healthcare environment.
13. Ability to lead cross-functional initiatives and influence executive decision-making across Finance, Legal, Revenue Cycle, Quality, and Clinical leadership.
14. Ability to serve as the primary escalation authority for payer denials, underpayments, enrollment issues, and operational challenges.
15. Ability to ensure compliance with organizational policies, regulatory requirements, confidentiality standards, and customer service expectations.