Director, Payor Partnership Enablement

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

Pediatric Associates Family of Companies is at an exciting phase of growth and investment, calling for a managed care expert to drive the seamless integration of our valued community physicians with our payor partnerships at national scale. The Director of Payor Partnership Enablement will be joining an organization with the deeply held purpose of delivering accessible, compassionate care of the highest quality to pediatric patients and their families.

 

This role will strategically evaluate, modify, and develop best practice business processes while enhancing practice profitability and improving daily operations. The Director of Payor Partnership Enablement is responsible for leading end-to-end provider roster management with payor partners to ensure contract payment integrity and foster positive patient and provider experience. The role will also provide thought leadership and value-based subject matter expertise to enable Pediatric Associates’ scale nationwide. The position is responsible for coordination and communication between managed care, leadership, and key stakeholders in credentialing, revenue cycle, finance, and IT. The new Director of Payor Partnership Enablement will model appropriate behavior as exemplified in Pediatric Associates Mission, Vision and Values, and play a critical role in the growth strategy and execution.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Leads end-to-end roster management processes and oversight across all fee-for-service and value-based payor agreements. Establishes tools, policies and standard operating procedures to ensure workflow efficiencies for onboarding and maintaining provider-payor partnerships in compliance with contractual terms and in accordance with state and federal regulations. Hardwires best practices to expedite provider and contract implementation readiness.
2. Responsible for preventing revenue disruption or delays in revenue forecasts with payor partners regarding updates to provider rosters including acquisitions, provider enrollments, panel transfers, TIN consolidation activities, changes in legal entities, or other material system changes that impact payor directories to foster a cohesive and positive member experience.
3. Maintains provider data accuracy with payors through routine roster audits and accountable oversight. Collaborates extensively with internal matrix stakeholders to monitor end-to-end roster management accountability for both delegated and non-delegated relationships.  Partners closely with national finance leaders in building and maintaining a provider membership dashboard. 
4. Collaborates with Business Development, Credentialing, Clinic Operations, Integration, Revenue Cycle, Finance, and Managed Care teams to monitor workflows for all PAFC Acquisitions, new provider hires, and other provider data changes. Assists directly in the due diligence process for new entity acquisitions and advises on successful provider integration and go-live implementation.
5. Collaborates with Revenue Cycle, Finance, and Managed Care teams to forecast capitated, incentive and value-based financials and/or other expected payment dates based on ingestion of payor data and provider effective dates. Assists in the root cause analysis of fee-for-service denial patterns, investigates the impact of provider configuration, and partners to resolve with payors.
6. Leads re-contracting efforts to resolve systemic issues with provider configuration to drive revenue cycle improvements and reduction of accounts receivable settlements.
7. Partners closely with IT and Data management teams to design standards for and facilitate payor integration of provider eligibility and effective date data.
8. Manages provider data accuracy with third-party data platforms (e.g. Innovaccer) and serves as liaison to clinical and population management teams in ensuring ongoing accuracy with data ingestion updates to impact quality metric attainment and forecasting.
9. Serves as subject matter expert in value-based care operations, contracting across all lines of business, and reimbursement methodology. Provides internal matrix partners with information about and develops managed care strategies and initiatives for contracting best practices, payor partnership processes, revenue cycle impacts, and industry trends impacting the Medicaid and commercial landscape.
10. Facilitates continuing payor contract performance success, identifying root causes affecting payment or operations and collaborates with internal and external stakeholders to resolve any discrepancies or complex issues swiftly and without patient disruption.
11. Performs other duties as assigned.

SUPERVISORY RESPONSIBILITIES

Heavily matrixed position, requiring influential leadership across national stakeholders. Delegates through others and provides accountable oversight for business processes and managed care objectives. May manage a direct team.

QUALIFICATIONS

EDUCATION: Bachelor’s degree in healthcare or related field required, Masters preferred. Education may alternatively be commensurate with 10 years of directly applicable experience.

EXPERIENCE: Minimum of 7 years combined payor and provider experience required.

KNOWLEDGE, SKILLS AND ABILITIES

• In-depth expertise of end-to-end payor loading, credentialing, configuration, and claims payment processes across all lines of business
• Extensive knowledge of compliance requirements with ability to implement policies and provide accountable oversight for all internal contracting operations processes
• Knowledge of Medicaid Managed Care programs and commercial contract parameters, reimbursement methodologies, contract language and performance
• Expertise in Risk and Value Based Contracting
• Effective strategic planning and organizational skills
• Advanced Microsoft Office skills
• Excellent oral and written communication, negotiation, and project management skills
• Ability to manage multiple priorities and projects
• Strong interpersonal skills with desire to collaborate and “get to yes”
• Ability to manage and influence others with and without direct supervisory responsibilities

TYPICAL WORKING CONDITIONS

• Non-patient facing
• Internal stakeholder and external partner facing.
• Full time remote. Must be U.S. based.
• Indoor desk-based work, operating computer and joining conference calls.
• Ability to travel as requested (<10%)

OTHER PHYSICAL REQUIREMENTS

• Vision
• Sense of sound
• Sense of touch
• Manual dexterity

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.