Director - Payor Relations & Contracting

SUBFUNCTION DEFINITION : Involves revenue cycle functions for the healthcare enterprise, including system billing, reporting and support.

Ensures account information contains accurate and comprehensive data to provide timely billing and optimal reimbursement for services.

Impacts processes to include charge capture, coding, insurance identification, data entry, billing, payment posting, refund processing and collections.

May also be responsible for / integrated with business office operations.

REPRESENTATIVE RESPONSIBILITIES

Contracting & Negotiations

Lead department and other internal staff and all applicable contract administrators to negotiate favorable contractual terms for Cincinnati Children's and / or the PHO.

Coordinate third party payer contract negotiation activities including settlements and acting as a liaison to and resource for internal operations and affiliates regarding third party payer contracting.

Prepare and implement annual contracting plan for CCHMC and PHO. Participate in the development of new business programs / ventures that include new payment arrangements with third party payers and employers.

Contract Management & Payer Compliance

Develop and maintain systems for oversight and monitoring of payer compliance with contracts in order to insure accurate and complete payment to CCHMC for all services covered in contracts with third party payers.

Work with Finance and clinical departments / divisions / Institutes to monitor third party payors' compliance with contract terms and payment rates and provide assistance in turning over payor denials.

Provide oversight and direct leadership of payor operational meetings (JOC) and escalate disputes related to payor policies and material claims disputes.

Develop contract management tools and systems for internal use by various departments and assist with the financial, operational and delivery aspects of third party payer and provider contracts.

Payer Relations

Develop and maintain appropriate working relationships with decision-makers and operating / clinical departments of third-party payers, insurance companies, employers, federal, state, local international government and private payers.

Conduct presentations and market Cincinnati Children's and PHO to third party payers, government officials, and employers.

Data Analysis & Pricing

Develop analytical reports to demonstrate the financial impact of current and proposed arrangements for physician, hospital, and PHO contracts.

Monitor and continually evaluate third party payer contracts. Review all contract fee schedules annually for appropriate maintenance and compliance.

Assist in development of regular benchmarking reports of pricing and reimbursement. Recommend annual fee schedule changes and pricing policies.

Financial Management

Manage the annual operating expense budgets of departments / costs centers reporting to position.

Qualifications

EDUCATION / EXPERIENCE

Required :

• Bachelor's degree in a related field
• 5+ years of work experience in a related job discipline
Preferred :
• MBA or MHA
• MBA or MHA
• Healthcare revenue cycle experience
• Healthcare contracting experience
• Negotiation experience (contracts)
• Experience reviewing payor policies

Cincinnati Children's is proud to be an Equal Opportunity Employer that values and treasures Diversity, Equity, and Inclusion.

We are committed to creating an environment of dignity and respect for all our employees, patients, and families. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, genetic information, national origin, sexual orientation, gender identity, disability or protected veteran status.

EEO / AA / M / F / Veteran / Disability

Management

Shift

Day Job

Job Type

Standard

Department

Payor Relations

Employee Status

Regular

Weekly Hours

Salary Range

52.66-81.93