Senior Director, Payer Strategy and Relations

Description

SCOPE:

Strategic: Leads all strategic development of third party payer strategies for Regional Cancer Care Associates (RCCA). Directs the formulation and execution of all managed care initiatives and strategies that will maximize opportunities with third party payers and provider p artners including hospitals and PCP networks and employers statewide.  Oversees managed care related policies, procedures and processes in support of strategic objectives. Develops and executes practice strategic planning and both long and short term goals to position Regional Cancer Care Associates optimally within the third party payer environment and local hospital/provider market. 

Prepares forecasts and advises senior management both within RCCA Practice Leadership on all matters concerning net revenues in the areas of Commercial Managed Care, Medicaid and Medicare. Develops and maintains payer relationships and advocates for the community-based oncology agenda with payers locally, identifying opportunities for enhanced relationships, reimbursement, referrals and a growing market presence. Overall, responsible for directing all contract negotiations and strategies to support revenue growth for Regional Cancer Care Associates.

Operational: Leads all strategies and negotiations to support alternative payment models with a focus on including novel payment models such as value-based reimbursement methodologies (i.e., case rate development, integrated networks, contract capitation, total cost of care initiatives and shared savings models) and has a firm grasp on the analytics/practice impacts that support such payment models. Serves as “expert” advisor to management team regarding maximizing revenue from managed care products and Medicare and Medicaid programs. Develops and makes recommendations regarding changes needed to enhance and optimize physician income and overall practice revenues. Ownership of key relationships between Regional Cancer Care Associates and health system partners to drive coordinated, high-quality care.

Program Outcomes: Collaborates with Quality team to develop alternative payment models and ensure delivery of compelling performance which results in gain share and optimization of quality measures. This includes incorporation of practice reporting, outcomes measures, etc. developed and used in support of such practice initiatives. Includes leadership and a focus to support risk-based contracts, claims studies, actuarial evaluations and episodic payments where gain share (or upside), steerage and other upside to the practice are included. 

Organizational Responsibilities: Creates a shared vision and demonstrates the ability to clearly articulate the organization’s desired position, creates a common goal for unity among groups with diverse interests and beliefs, clearly communicates the organization’s mission, strategies, goals and priorities, defines team members’ roles and responsibilities, seeks input and buy-in from team members and establishes alignment throughout the organization. Supports and adheres to Compliance Program, including the Code of Ethics and Business Standards.

Combines judgment, extensive experience and business and industry knowledge to make sound decisions.

Requirements

 ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Plans, develops, directs, coordinates and monitors all managed care activities to      successfully bring to market new products, methodologies, and strategies and to negotiate compelling contracts with both payers and providers (where appropriate).
• Works with RCCA operations, finance, Managed Care team and the pharmacy team, directs and advises on strategies and solutions, and sets benchmarks to ensure that contracts negotiated in accordance with budgeted objectives to obtain maximum profitability and volume in relation to pre-set standards and specific trends within the industry.
• Evaluates practice trends and variances for planning and provides information to senior management and field. Communicates and educates all internal customers as to the prudent and most effective manner with which to deal with payers.
• Develops and recommends payer pricing, contracting and operational strategies to optimize the long-term financial profitability of the practices and the company. Evaluates opportunities to take financial risk and looks proactively to ensure a longer term, compelling strategy to ensure a growing referral base, market differentiation and practice growth.
• In coordination with the revenue cycle leadership, evaluates, sources, designs, recommends and monitors the execution and effectiveness of policy, procedure and processes designed to ensure timely and accurate reimbursement from payers.