Director of Payor Relations

Vertava Health This is a remote role

Director of Payor Relations


Vertava Health is a leading national behavioral healthcare system for mental health and substance use disorders, providing a full continuum of services based on the individuals' varying needs at different times in their health and recovery journey. We apply evidence-based treatment modalities at every level of care and embed digital health tools to enhance and amplify clinical outcomes. With a growing list of Joint Commission accredited inpatient and outpatient locations across the country, a virtual care platform and a national network of healthcare providers, Vertava Health pioneers care that empowers people so that they can live out their best future.

In order to make this possible, we need an exceptional Director of Payor Relations who can meet the requirements below. Think you have what it takes to help us change lives all over the country?

Job Summary:

The Director of Payor Relations manages Payor patient populations, their associated risk and determinants of health, while driving improvement in health outcomes. They will have direct relationships with various clinical integration teams and processes (care coordination, complex care management, post-acute programs, chronic conditions, evidence-based care guidelines, bundles, social determinants of health, and population health). This person will be accountable for delivering on contract and programmatic performance metrics across all payor classes (Commercial, Direct to Employer). The Director of Payor Relations will work closely with the various senior administrative and clinical leaders, leadership teams, and Payor network members. They will build strong collaborative working relationships with each of these groups. They must be comfortable operating in a matrix environment to be effective. This individual will bring a working understanding of Alternative Payment Models, healthcare planning, payor contracting, healthcare analytics, and financial principles. Lastly, will lead all aspects of provider network strategy including, access analysis, network operations and support decision makers with analysis related to reimbursement and unit cost management. Oversee the coordination and negotiation for the contracting department. You will be managing a team of 1 Sr. Contracts Manager and 1 Credentialing Specialist.

Priority responsibilities include:

· Establishes a comprehensive Alternative Payment Model strategy and program that supports the organization’s strategy, mission, vision, values, and goals.

· Develops and continually tests and refines appropriate interventions ensuring care at the right time, right provider, right place, and that is high quality and cost-effective.

· Drives integration and alignment of various clinical and operational strategies to support Alternative Payment Models

· Responsible for the development and oversight of all Alternative Payment Models and related care integration programs.

· In partnership with the SVP Clinical and Quality, oversees all Alternative Payment Model operations and provides high-level direction and consultation, review, and direction to all internal departments, hospitals, practices, and continuum partners.

· Develops and maintains a state-of-the-art approach for the following:

o Population risk stratification and segmentation;

o Understanding and impacting social determinants/influencers of health;

o Addressing disparities in health outcomes and care processes that produce them;

o Evidence-based management of BH and SUD related conditions;

o Effective use and maximization of care integration and management processes;

o Maximization of preventative and wellness opportunities;

o Quality measurement and reporting;

o Assessing patient experience and satisfaction; and

o Seeking appropriate clinical input and involvement.

· Provides strategic input into alternative payment model contracts and other contract negotiations, e.g. care model design, reimbursement, structure and approach for bundle payment models, Centers of Excellence, Direct to Employer, and capitation, partial and/or risk models.

· Oversees the development of programmatic level metrics and targets for purposes of delivering on expected outcomes.

· Implements process improvement efforts to accelerate and drive an agenda of operational efficiency and clinical excellence.

· Ensures data requirements are met for required external reporting (commercial payers, and adherence to Evidence Based programs).

· Revises guidelines, plans, policies, and procedures to support programmatic, regulatory, and compliance needs.

· Responsible for programmatic operating and medical economics/data budgets associated Alternative Payment Models

· Ensures information is communicated vertically and laterally across the network as needed, and keeps leadership informed of any issues.

· Develops a collaborative team-based environment that drives clinically appropriate outcomes across the continuum

· Manages all Credentialing Functions


· Bachelor’s Degree or MBA or MHA in business admin or healthcare administration

· 10+ years of experience in network development, medical economics and contracting

· Either managed care experience or experience contracting on provider’s side (hospital)

· 7+ year’s management experience

· Understanding the risk factors (ability to look at a contract and understand what would put the plan in a risky situation)

· Demonstrate high level negotiation and problem-solving skills

· Superb people manager and experience successfully managing resources and budgets

· Substantial working knowledge of Alternative Payment Models, accountable care processes, payor contracting, and the fundamentals of clinical integration.

· Sound understanding of principles and current best practices and the discipline of Alternative Payment Models with a solid understanding of value-based care principles and industry trends.

· An understanding of current Alternative Payment Model strategies such as shared savings, partial and full risk methodologies, case and disease management, demand management, resource utilization, and risk assessment.

· Experience in advancing care management and utilization review to effectively place patients in the right setting and organize resources with a systems mindset.

· Possess a significant understanding of the full continuum of care and the movement of patients to the appropriate setting.

· Excellent analytical, tactical, execution, and organizational abilities required, conceptualizing well in unstructured, fast-paced, dynamic, and multi-functional environments.

· Demonstrated ability to skillfully counsel, collaborate, inspire, and build confidence in others; create alliances, obtain support and respect from diverse groups and foster an understanding and commitment to the organization.

· Possess a track record of developing a good rapport with Payors, physicians and clinical staff with the ability to grow and maintain relationships.

· Demonstrated successful program development, change management, relationship building, and staff development in prior leadership roles.

· Ability to analyze and use data to influence change.

· Exposure to, and experience in, the design and implementation of scalable process and quality improvement activities

· Excellent problem solving and negotiation skills – effective at conflict management.

· Proven success with leading Payors and clinical leaders to pursue operational excellence and effective patient outcomes and strong patient satisfaction.

· Knowledge of industry and regulatory program policies, procedures, and laws.

Physical Requirements:

· Ability to use hands and fingers, talk or hear

· Ability to sit, stand, walk and reach continually. Ability to climb or balance, stoop, kneel, or crouch frequently

· Close vision required to see computer monitor, read documents, and operate copy and fax machine

Vertava Health is an EEO employer - M/F/Vets/Disabled
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