Senior Director, Payer Relations

Company: Tennessee Hospital Association
Location: Nashville
Posted on: March 8, 2025

Job Description:

We have a hybrid work arrangement. EOE: race/color/religion/sex/sexual orientation/gender identity/national origin/disability/vet JOB SUMMARY: Coordinates with a network of hospital and health system managed care, revenue cycle, and compliance professionals. Provides in-depth research, support, education, and advocacy around issues of healthcare reimbursement and compliance, including managed care (commercial, Medicaid, and Medicare Advantage), TennCare, workers' compensation, payment innovations, changes in methodologies, and program integrity. Utilizes data, when possible, to demonstrate impacts of payer issues. Assists in the creation of educational and professional development opportunities for member hospitals related to current and emerging topics in managed care, revenue cycle, and compliance. ESSENTIAL FUNCTIONS OF THE JOB:1. Provide in-depth research, support, education, and advocacy for members around issues of healthcare finance and reimbursement. Serve as a resource and respond to member inquiries on these issues in a timely and effective manner.Provide a forum for addressing members' issues with payers and represent THA members around common administrative matters. Work with hospitals to identify, research and then negotiate solutions to, or mitigate the impact of, common issues that hospitals encounter with payers (commercial, Medicaid, or Medicare Advantage). Communicate regularly with hospital members around current developments impacting reimbursement, providing education on changes as well as receiving input on their concerns.Evaluate and provide feedback on payer proposals and plans to implement policy changes impacting hospital operations or payment; analyze potential impacts and educate members.Provide input and make recommendations into the development of TennCare policy and reimbursement issues. Provide education and advocacy around transitions and programmatic changes within the TennCare program as well as TennCare operational issues, reimbursement methodologies, and benefit changes.As needed, work with the TennCare MCO Operations team and the TennCare Oversight Division of the Tennessee Department of Commerce & Insurance to address issues and concerns regarding the TennCare Managed Care Organizations (MCOs).As needed, work with the Tennessee Department of Commerce and Insurance to address issues and concerns regarding commercial payers.Monitor proposed state changes to workers' compensation payment methodology, fee schedule, and rules. Identify concerns, develop recommendations, and share impacts with THA leadership.Monitor changes in the Medicare Advantage program and commercial payer policies and as needed, communicate changes and potential impacts with members.Work with other states on national payer issues, including surveying members and payer scorecards, develop policy responses to payers and participate in meetings with state and national payers regarding administrative and operational issues.Participate in CMS Region IV calls to stay abreast of Medicare and Medicare Advantage issues impacting members. Advocate for solutions to issues impacting Tennessee hospitals.Assist in the planning and execution of educational opportunities for members associated with reimbursement and managed care best practices, payer updates, and exchange plan offerings.Assist in the planning of the multi-state managed care conference.2. Provide subject matter support for various THA workgroups.Participate as needed in Inpatient Rehab Facility (IRF), Long-term Acute Care Hospital (LTACH), Home Health, Behavioral Health, and other workgroups as needed.Assist in the facilitation of the managed care, revenue cycle, and compliance workgroups.o Aid in the development of agendas based on current issues, trends, regulatory advisories, member feedback, etc.o Help create presentations as needed for the workgroups to foster communication and discussion.o Ensure compliance with all laws, especially paying close attention to federal antitrust regulations.o Maintain notes from the workgroup meetings and share them with workgroup members.o Follow up on and assist members in resolving issues as applicable.3. Provide in-depth research, support, education and advocacy for members around healthcare compliance issues and program integrity. Provide a statewide focal point for compliance education and compliance officers. Respond to member queries on these issues.Provide in-depth research and assist in coordinating education on current topics in healthcare compliance.Monitor and research proposed governmental program changes and make recommendations based on knowledge of their impact on hospital operations.Provide forums for those responsible for compliance and program integrity in hospitals to discuss issues. Assist in the planning and execution of THA's annual compliance conference and other compliance education as needed.Partner with healthcare fraud enforcement agencies (including but not limited to US Attorney offices, Medicaid program integrity and CMS Office of Inspector General) to keep lines of communication open and to provide current information to members.4. Maintain payer scorecard system and inpatient rehabilitation facility (IRF) payer database. Review data for trends and make recommendations to address identified issues and ways to improve THA's use of payer data. As applicable, respond to member inquiries regarding payer scorecard system or IRF payer database.5. Review proposed state and federal legislation and assist in drafting talking points for the advocacy teams. Provide feedback about potential impacts to hospital finances and operations resulting from proposed bills and assist in gathering feedback from members, including the applicable workgroups, to assist with impact analyses.6. Must have the ability to adapt to a changing work environment and meet challenges presented throughout the day.7. Must be available for out-of-town travel approximately 10 percent of the time, be able to drive an automobile and maintain a valid driver's license. Must travel both within and out of the state for various meetings as needed.8. Must be available in the office during regular office hours unless job responsibilities require otherwise, or hybrid work arrangement is in place. ORGANIZATIONAL STRUCTURE: (Positions reporting directly to this position.)NoneGUIDANCE & DIRECTION: (Policies, precedents or procedures that guide this work.)1. Reimbursement and compliance rules (commercial or governmental) must be known, followed, and considered Educational and experience Requirements Needed to Perform the Duties of the Job:1. Educational requirement: Bachelor's degree in accounting, finance, or other related field required. 2. Minimum of five years' experience in health care required. Background experience and knowledge should include: -Detailed knowledge of hospital revenue cycle and/or managed care-commercial, Medicare Advantage, Medicaid, and workers' compensation, including: Reimbursement methodologies Financial analysis Legal/contractual issues Reimbursement audits Investigation and resolution of payment errors Operational issues Measuring contract performance -Hospital and/or health system operations experience desired -General knowledge of the following as it relates to hospitals: Accounting/auditing Billing and collections Healthcare compliance Health information management Utilization management Quality & accrediting bodies3. Experience with the following: Managing or conducting reimbursement analysis/negotiation Contractual language Operationalizing financial arrangements Identifying and resolving issues involving reimbursement, hospital operations, and healthcare compliance Building and managing relationships with managed care payers/outside entitiesSkills Required to Perform the Duties of the Job:1. In-depth understanding of hospital or healthcare operational, technical, regulatory, and contractual issues and procedures.2. Must be analytical and able to ascertain and process facts related to a potential concern and use good judgment as to whether problems actually exist or need to be escalated.3. Must have strong problem-solving skills and be able to find solutions through detailed research, strategic thinking, and effective communication.4. Ability to understand both sides of a dispute and move toward resolution/mitigation of issue.5. Ability to work constructively with payers and maintain positive working relationships while advocating for hospital members.6. Must have excellent written and verbal communication skills.7. Must have the ability to take complex issues and explain them in an appropriate manner based on the knowledge level of the audience.8. Must be able to think through creative ways to solve problems. Must be able to navigate and negotiate complicated multi-faceted issues within complex relationships. Needs to be able to understand the interconnectedness of the healthcare finance environment.9. Must be proficient in Microsoft Word, Outlook, Excel, PowerPoint, and Teams.Compensation details: 115000-125000 Yearly SalaryPIabe0fd0a9be5-25660-37106154

Keywords: Tennessee Hospital Association, Nashville , Senior Director, Payer Relations, Executive , Nashville, Tennessee