Director, Payor Contracting

Central Ohio Primary Care is seeking a full time Director Payor Contracting at our central business office in Westerville OH. The Director Payor Contracting is responsible for leading rate negotiations and managing payor relationships across commercial Medicare Advantage and Medicaid managed care lines of business on behalf of COPC. This position is responsible for the contract execution implementation quality control auditing and issue resolution processes that support accurate competitive and properly designed and executed payor agreements This position negotiates and manages both fee-for-service and value-based care (VBC) agreements including shared savings risk and quality incentive arrangements and partners closely with COPCs Clinical Quality and Population Health teams to ensure VBC terms are clinically achievable appropriately resourced and aligned with organizational quality performance capabilities. Additionally this role is charged with building and maintaining strong strategic relationships with payor representatives executives and internal stakeholders to ensure alignment with COPC goals and objectives.

POSITION(S) SUPERVISED: N/A

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Lead end-to-end rate negotiations with commercial Medicare Advantage and Medicaid managed care payors from strategy development through final execution serving as the organizations primary point of contact and lead negotiator with health plan representatives; assess and defend rate proposals using market benchmarking and financial impact analysis; draft redline and finalize contract language in coordination with legal and operational leadership.

Review payor contracts amendments and fee schedules for accuracy prior to execution and maintain a centralized up-to-date contract repository with correct effective dates and rate terms.

Maintain ongoing collaboration with the quality team throughout the contract term to monitor performance against VBC benchmarks flag misalignment early and inform renegotiation strategy at renewal.

Investigate discrepancies in efficiency and utilization metrics (e.g. cost per episode ED/inpatient utilization resource use trends) tied to VBC contract performance; prepare clear reports summarizing findings and trends for review by clinical and quality leadership.

Build and maintain financial models to evaluate proposed rates and reimbursement terms against current and projected patient volumes; prepare rate comparisons payor scorecards and performance dashboards for leadership.

Build and maintain financial models that incorporate quality bonus/withhold structures shared savings/risk corridors and Star Ratings-linked incentives.

Serve as the point of escalation for payor-related issues; log categorize and monitor issues through resolution and provide leadership with regular status updates on open issues trends and resolution timelines.

Perform periodic quality checks on fee schedules loaded into claims and billing systems to confirm alignment with executed contract terms and establish standardized workflows to reduce contract data errors.

Conduct routine audits of paid claims against contracted rates to identify discrepancies recover underpayments and validate that payor configurations in internal systems reflect current contract terms.

Partner with billing and revenue cycle teams to audit denial trends tied to contract terms document audit findings and recommend corrective actions.

Analyze payor claims reimbursement and utilization data to identify rate trends underpayments and opportunities to strengthen contract terms across the payor portfolio.

Additional duties as assigned.

QUALIFICATIONS:

A. Education Licensures & Certifications

Required: Bachelors Degree in Business Finance Healthcare Administration or other related discipline.

Required: Minimum of seven (7) years progressive experience in payor contracting or managed care including a demonstrated track record of leading and closing rate negotiations with commercial and government payors.

B. Knowledge Skills & Abilities

Superior negotiation skills with a demonstrated track record of securing favorable reimbursement terms with commercial and government payors.

Experience negotiating risk arrangements: shared savings full/partial cap MA percent-of-premium quality withholds

Familiarity with ACO REACH/LEAD/MSSP HCC risk adjustment Stars/HEDIS gap closure economics

Ability to model downside risk exposure before signing

Strong financial and analytical acumen.

Excellent organizational skills and ability to develop processes and follow up.

Ability to work independently and in a team environment; and leading by example.

Ability to evaluate and analyze reimbursement and claims data to identify viable cost-effective contracting strategies and rate improvement opportunities.

Ability to multi-task prioritize manage time effectively and respond timely.

Ability to demonstrate a high level of confidentiality.

Excellent computer skills including experience with Microsoft Office programs (Word PowerPoint Excel Teams) and claims/billing systems preferably Epic.

Required Experience:

Director