Director of Payer Relations and Contracting

OMS MEDICAL BILLING LLC•Addison, TX

1d•Onsite

About The Position

OrthoMed Anesthesia is seeking an experienced Director of Payer Relations and Contracting to serve as the organization’s single point of contact with payers. As a mostly out-of-network anesthesia practice, the organization’s reimbursement depends on payer compliance with the No Surprises Act, state surprise billing law, and plan terms, as well as appropriately structured agreements where in-network participation makes sense. The Director owns payer relationships end to end, from day-to-day escalation through contract negotiation and execution, and is expected to bring established payer relationships and a track record of negotiating and closing agreements. The Director leads payer strategy, negotiations, and escalations; defines analytical requirements for payer scorecards and network participation models; partners with RCM leadership and the data and engineering team to produce analysis; and presents recommendations to executive leadership. The role is based on-site at the corporate headquarters in Addison, Texas, during regular business hours, with periodic travel for payer meetings, negotiations, and industry events.

Requirements

Bachelor’s degree in Healthcare Administration, Finance, Business, or a related field, or equivalent professional experience.
At least 10 years of provider-side experience in payer relations, managed care contracting, or provider network management, with significant experience in anesthesia or another facility-based specialty such as emergency medicine, radiology, or pathology.
Demonstrated track record of negotiating and closing payer agreements, including negotiating rates and contract language through execution.
In-depth knowledge of anesthesia contract structures, including conversion factors, ASA base units, time units, medical direction and concurrency, and anesthesia modifiers.
Existing working relationships with contracting and provider relations leaders at major commercial payers; Texas-market relationships are ideal.
Working knowledge of the No Surprises Act, including QPA, initial payment and denial timelines, open negotiation, and federal IDR, as well as Texas surprise billing regulations.
Ability to evaluate contract proposals and reimbursement scenarios, including rate comparisons, payer mix analysis, and in-network versus out-of-network yield, and to direct analysts producing supporting models.
Strong negotiation skills and executive presence, with the ability to represent the organization with senior payer contacts and present data-driven recommendations to executives.
Advanced Excel skills.

Nice To Haves

Anesthesia experience is strongly preferred.
Familiarity with business intelligence tools such as Power BI, Tableau, or Sigma.
Master’s degree, such as an MBA, MHA, or similar.
Experience in an out-of-network or IDR-heavy reimbursement environment, including moving payers between out-of-network and in-network status.
Payer contracting experience for multi-site physician groups or anesthesia management companies.
Familiarity with claims and remittance data (837/835, CARC/RARC) and anesthesia billing platforms such as PhyGeneSys.
HFMA (CRCR), AAPC, or similar certification.

Responsibilities

Own payer-by-payer network strategy, including decisions about in-network participation, out-of-network status, and conditions for changing those positions.
Establish and maintain the methodology for evaluating in-network versus out-of-network status, considering reimbursement yield, IDR outcomes, cost to collect, proposed contract rates, encounter volume, patient balance exposure, facility and surgeon network requirements, administrative burden, and regulatory risk.
Present payer-level recommendations and supporting financial models to executive leadership for decision.
Re-evaluate payer positions on a defined cadence and in response to trigger events such as contract offers, facility network demands, shifts in IDR outcomes, or regulatory changes.
Lead payer contract negotiations from initial outreach through execution, including rate proposals, counterproposals, and contract language, within leadership-approved parameters.
Structure anesthesia agreements, including conversion factors, base and time unit methodology, medical direction and concurrency provisions, modifier treatment, rate escalators, timely filing, and termination terms.
Coordinate contract review with Legal, Finance, and Compliance, and coordinate enrollment and effective dates with Credentialing.
Maintain a contract inventory with key terms, renewal and notice dates, and rate schedules; monitor contracted payers’ adherence to agreed rates and terms and pursue variances.
Ensure executed agreements are accurately loaded and reflected in billing systems and expected-reimbursement logic.
Serve as OrthoMed’s single point of contact with payers across provider relations, network management, claims escalation, and IDR operations.
Lead recurring operating reviews with key payers to resolve systemic issues and track commitments to closure.
Escalate systemic payment issues using documented, quantified evidence, and maintain an escalation log tracking dollars at risk, payer response, and resolution status.
In coordination with Compliance and leadership, pursue unresolved issues through applicable regulatory complaint channels, including the CMS No Surprises Help Desk and the Texas Department of Insurance.
Define metrics, logic, and reporting requirements for payer scorecards, including payment timeliness, payment adequacy relative to QPA, IDR outcomes, contracted rates, denials, downcoding, records requests, recoupments, and appeal overturn rates.
Partner with RCM leadership and the data and engineering team to produce scorecards, contract models, and supporting analysis, and validate results before use in negotiations or leadership reporting.
Present scorecard findings and recommended actions to leadership on a defined cadence, including monthly operational and quarterly executive reviews.
Monitor payer behavior and policy changes, including anesthesia-specific policies, QPA methodology changes, and new plan products, and communicate their operational and financial impact.
Align denial metrics and definitions with the Accounts Receivable Manager and route internally caused denial root causes to Billing, Coding, Credentialing, or Clinical teams.
Serve as the internal subject matter expert on payer contracting, policies, and processes, and distribute payer policy change summaries to RCM teams.
Partner with RCM Leadership, the Accounts Receivable Manager, IDR team, Credentialing, Compliance, Legal, Finance, and RCM Transformation.
Perform additional duties as needed in alignment with OrthoMed Anesthesia’s mission.