The Senior Manager, Payor Contracts plays a pivotal role in ensuring the financial success and operational efficiency of the organization by overseeing payor contract analysis and implementation. This working manager combines expertise in reimbursement strategies with a collaborative leadership style, driving alignment between operational teams and executive goals. The role ensures compliance, fosters payor relationships, and optimizes financial outcomes in home infusion therapy and specialty pharmacy operations.
Responsibilities
- Review payor contracts and related amendments and providing related recommendations to all operational teams
- Evaluate proposed reimbursement rates (e.g., per diem, drug rates) against benchmarks and industry standards.
- Oversee end-to-end processes aligned with implementation timelines, including payor credentialing applications.
- Provide consultation, education, and training on contract requirements to Intake and billing/collection teams, including information regarding payor reimbursement methodologies, rates, and policies
- Collaborate cross-functionally to ensure accurate data entry of payor rates for authorizations, billing, and claims.
- Maintain the knowledgebase particular to benchmark rates and managed care terms; leverage this data to inform health system partner strategies
- Manage payor contract and amendment reimbursement related reference materials to support other teams (e.g., Intake, Billing/Collections)
- Work with billing & collections teams to review payor payment trends, and investigates payment variances for payor contract non-compliance; leverage payor relationships/contacts to assist in collecting outstanding AR and reversing denials
- Drive improvement in contract compliance and reimbursement turnaround times.
- Other duties as assigned.
Skills & Abilities
- Minimum of 10 years in payer or contract management, specializing in specialty pharmacy, infusion therapy, or related fields.
- Extensive knowledge of home infusion therapies, associated drugs, and HCPCS coding.
- Advanced knowledge of health insurance plans: Managed Care Organizations, PPO, POS, Self-Funded, TPAs and providers at financial risk (hospital/health systems, medical group/IPA).
- Knowledge of HIPAA guidelines, federal, state, and local regulations related to pharmacy or healthcare providers
- Ability to manage multiple priorities, work independently, and support staff training initiatives.
- Proficiency in Microsoft Excel, Microsoft Word, and PowerPoint
- Experience with CPR + system preferred
Requirements
- Bachelor's Degree preferred or equivalent business experience of ten (10) years.
