Payor Contract & Reimbursement Manager

Overview of the Position:

The Payor Contract & Reimbursement Manager is responsible for the analysis, interpretation, implementation, maintenance, and optimization of all payor contracts across the HopeHealth network. This position serves as the subject matter expert for Government, State Medicaid, Medicare, Medicare Advantage, Managed Care Organizations (MCOs), Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Commercial, and Value-Based reimbursement arrangements.

This role collaborates closely with Revenue Cycle, Finance, Operations, Provider Enrollment, Compliance, and Clinical Leadership to ensure reimbursement methodologies are accurately implemented, contractual obligations are met, and organizational financial performance is optimized. The position is responsible for contract modeling, reimbursement analysis, payor performance monitoring, contract compliance, and supporting negotiations to ensure favorable reimbursement and alignment with HopeHealth's strategic goals.

Qualification (Required)

Qualifications (Preferred)

• High School Diploma or equivalent required.
• Three (3) to five (5) years of healthcare finance, reimbursement, revenue cycle, managed care contracting, or related experience.
• Experience with Medicare, Medicaid, Medicare Advantage, Managed Care, Commercial, PPO, HMO, and Value-Based reimbursement methodologies.
• Strong analytical and financial modeling skills.
• Advanced proficiency in Microsoft Excel, including Pivot Tables, VLOOKUP/XLOOKUP, formulas, and data analysis.
• Knowledge of healthcare reimbursement structures claims processing, and revenue cycle operations.
• Ability to interpret complex contract language and reimbursement methodologies.
• Strong written and verbal communication skills with the ability to present findings to leadership.
• Bachelor's degree in healthcare administration, Finance, Business Administration, Accounting, or related field.
• Five (5) or more years of experience in managed care contracting, reimbursement analysis, healthcare finance, or revenue cycle leadership.
• Experience supporting executive leadership and contract negotiations.
• Federal Qualified Health Center (FQHC) reimbursement experience, including PPS and wrap payment methodologies.
• Knowledge of HEDIS, quality metrics, value-based care initiatives, and population health reimbursement programs.
• Experience with contract management software, EMR systems, and healthcare analytics platforms.
• Tableau, Power BI, or similar reporting platform experience.
• Certified Revenue Cycle Representative (CRCR), Certified Healthcare Financial Professional (CHFP), or similar certification preferred.

Supervisory Responsibilities:

• No direct supervisory responsibilities. • May provide guidance, education, and subject matter expertise to internal departments regarding payor contract terms and reimbursement methodologies.

Essential Job Functions:

• Review, analyze, interpret, and maintain new and existing payor contracts to ensure financial viability, compliance, and alignment with organizational goals.
• Develop reimbursement models and perform financial impact analyses utilizing Medicare, Medicaid, Managed Care, Commercial, and Value-Based payment methodologies.
• Support contract negotiations by providing reimbursement analysis, benchmarking, financial projections, and contract performance evaluations.
• Maintain a comprehensive repository of payor contracts, amendments, fee schedules, reimbursement methodologies, and contract-related documentation.
• Monitor contract compliance and ensure contractual obligations are accurately implemented throughout the organization.
• Collaborate with Revenue Cycle, Finance, Operations, Compliance, and Clinical Leadership to ensure contract terms are operationalized and reimbursement is optimized.
• Analyze contract performance and identify opportunities for reimbursement improvement, operational efficiencies, and revenue enhancement.
• Monitor and investigate underpayments, payment variances, reimbursement discrepancies, and contract compliance concerns.
• Work collaboratively with billing and revenue cycle teams to resolve reimbursement issues and support recovery of identified underpayments.
• Validate reimbursement methodologies and assist with contract loading and maintenance within applicable systems.
• Monitor federal, state, and commercial payor regulatory changes and assess potential impacts to reimbursement and operations.
• Analyze and report on reimbursement trends, contract performance metrics, and strategic opportunities.
• Develop reports, dashboards, scorecards, and presentations for executive leadership and organizational stakeholders.
• Participate in meetings with payors and organizational leadership as the subject matter expert for reimbursement methodologies, contract terms, and financial performance.
• Evaluate the financial impact of new service lines, provider additions, organizational growth initiatives, and reimbursement changes.
• Collaborate with Provider Enrollment and Credentialing teams to ensure contracted providers are appropriately enrolled and recognized by payors.
• Support value-based care initiatives by monitoring quality incentive programs, shared savings arrangements, risk-based contracts, and other alternative payment models.
• Assist with FQHC reimbursement analysis, including PPS methodologies, wrap payments, quality incentives, and related reimbursement programs.
• Conduct pro forma analyses, cost studies, reimbursement forecasts, and service line profitability assessments.
• Assist with audits, compliance reviews, financial analyses, and special projects as assigned.
• Maintain confidentiality of all financial, contractual, provider, and organizational information.
• Perform additional duties and responsibilities as assigned.

Physical Requirements:

Must possess the ability to communicate in the dominant language of the geographic region. Must be able to lift 30 pounds. Vision and hearing corrected to within normal limits is required. Must have manual dexterity to key in data; utilize computer, grab, grip, hold, tear, cut, sort, and reach.