Pediatric Associates was founded in Hollywood, FL in 1955. The same clinician-led, evidence-based, medical home passion is a unifying driver for those who join Pediatric Associates Family of Companies. The Pediatric Associates Family of Companies is a growing team of Pediatricians and Pediatric Care Teammates who are excited to be part of the first nationwide Pediatric Primary Care Medical Home. We further our uniqueness by ensuring the clinician voice is leading our medical home innovations.
PRIMARY FUNCTION
The Senior Payor Relationship Manager is responsible for payor relationship management and understanding the payor needs and payor landscape for their assigned markets. This position facilitates the successful resolution of all outstanding operational issues identified by internal PA Family of Companies members. This position works closely with Managed Care Operations and directly reports to the Director of Payor Relations for their assigned market.
ESSENTIAL DUTIES AND RESPONSIBILITIES
This list may not include all of the duties that may be assigned.
- Supports the Director of Payor Relations in Value-Based and Fee for Service negotiations; proactively monitors the payor landscape in the assigned market to maximize the competitive position of the PA Family of Companies.
- Develops and maintains strong payor relationships and serves as the primary point of contact for assigned market.
- Facilitates Payor meetings with all VBC and large complex payor relationships for assigned markets.
- Tracks and manages the full life cycle for all payor contracts and amendments from beginning to full execution for all contracts, including Risk, Value Based, Fee for Service, and Capitation payment methodologies.
- Escalates contract language concerns to Managed Care Operations Team.
- Monitors payor contract performance (to include Capitation, Gainshare, Pay for Performance, and Incentive Programs) and identifies areas of opportunities.
- Monitors, tracks, evaluates, and assists Managed Care Operations in the resolution of payment inconsistencies, which include Capitation, Gainshare/Risk, Pay for Performance, and other Incentive arrangements
- Coordinates with the Managed Care Operations to ensure compliance with state and federal regulations for contract terms and legal regulations that may impact the performance of the contract for assigned market.
- Resolves and appropriately escalates all payment, loading, payor communications, and requests.
- Performs rate evaluation based on modeling and analysis and evaluates/monitors contract performance and contract compliance.
- Other Duties as assigned.
QUALIFICATIONS
EDUCATION:
• A bachelor’s degree in healthcare administration or business is required. Master’s degree preferred.
• A minimum of 5 years of related experience will be commensurate with education.
EXPERIENCE:
- Minimum of 5 years’ of combined payor and provider experience required.
- Previous healthcare experience required.
KNOWLEDGE, SKILLS AND ABILITIES
- In-depth understanding of contract parameters, reimbursement methodologies, contract language and performance.
- Knowledge in Risk and Value Based Contracting
- Effective strategic planning and organizational skills
- Knowledge of Statewide Medicaid Managed Care programs and Commercial payors
- Proficient in research, analysis, and interpretation of financial data and trends
- Knowledge of reimbursement methodologies and CPT, ICD10, RBRVS, and capitation.
- Knowledge of claims, credentialing, and loading processes
- Advanced Microsoft Office skills
- Effective oral and written communication and negotiating skills.
- Ability to manage multiple priorities and projects.
- Strong interpersonal skills
- Ability to influence others
LICENSURE/CERTIFICATION:
*Upon hire, and for the duration of the employment period driver’s license must be active and valid.*
TYPICAL WORKING CONDITIONS
- Non-patient facing
- May be either full time remote or rotate working in the office.
- Must be U.S.-based.
- Indoor Work
- Operating Computer
- Reach Outward
- Reach above Shoulder
- Lift/Carry 11-20lbs.
- Standing
- Sitting
- Traveling
- Walking
- Bending
- Manual Dexterity
OTHER PHYSICAL REQUIREMENTS
- Vision
- Sense of sound
- Sense of touch
PERFORMANCE REQUIREMENTS
Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI (Protected Health Information) in accordance with organizational policy, Federal, State, and local regulations.
The Pediatric Associates Family of Companies an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
