Director of Payer Relations and Contracting

Director of Payer Relations and Contracting

Location: Corporate Headquarters, Addison, TX (On-site)

Position Type: Full-Time

Position Summary

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, OrthoMed's reimbursement depends on payer compliance with the No Surprises Act (NSA), state surprise billing law, and plan terms, as well as on well-structured agreements where in-network participation makes sense. This role owns the payer relationship end to end, from day-to-day escalation through contract negotiation and execution.

The Director brings established payer relationships and a track record of negotiating and closing agreements and is expected to engage payers credibly from day one. The Director leads payer strategy, negotiations, and escalations; sets the analytical requirements for payer scorecards and network participation models and partners with RCM leadership and the data and engineering team to produce them; and presents recommendations to executive leadership.

Key Responsibilities

Payer Strategy and Network Participation

- Own the payer-by-payer network strategy, including which payers to pursue for in-network participation, which to remain out-of-network with, and the conditions under which that position should change

- Establish and maintain the methodology for evaluating in-network versus out-of-network status, weighing out-of-network net yield (including IDR outcomes and 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, with supporting financial models, to executive leadership for decision

- Re-evaluate payer positions on a defined cadence and on trigger events such as a payer contract offer, facility network demands, material shifts in IDR outcomes, or regulatory change

Contract Negotiation and Management

- Lead payer contract negotiations from initial outreach through execution, including rate proposals, counterproposals, and contract language, within parameters approved by leadership

- Structure anesthesia agreements appropriately, including conversion factors, base and time unit methodology, medical direction and concurrency provisions, modifier treatment, rate escalators, timely filing, and termination terms

- Coordinate with Legal, Finance, and Compliance on contract review, and with Credentialing on enrollment and effective dates

- Maintain a contract inventory with key terms, renewal and notice dates, and rate schedules; monitor contracted payers for adherence to agreed rates and terms and pursue variances

- Ensure executed agreements are accurately loaded and reflected in billing systems and expected-reimbursement logic

Payer Relationships and Escalation

- 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 (late payment, underpayment, inappropriate denials, failure to pay IDR determinations) with 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 regulatory complaint channels, including the CMS No Surprises Help Desk and the Texas Department of Insurance, as applicable

Payer Performance and Analytics

- Define the metrics, logic, and reporting requirements for payer scorecards covering payment timeliness (including adherence to the NSA 30-day initial payment or notice of denial requirement), payment adequacy relative to QPA, IDR outcomes, and contracted rates, denial rates and categories, downcoding, records-request frequency, recoupments, and appeal overturn rates

- Partner with RCM leadership and the data and engineering team to produce scorecards, contract models, and supporting analysis; validate results before they are used in negotiations or shared with leadership

- Present scorecard findings and recommended actions to leadership on a defined cadence (monthly operational, quarterly executive)

- 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

Leadership and Collaboration

- Serve as the internal subject matter expert on payer contracting, policies, and processes; 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

Key Performance Measures

- Working relationships established with contracting and provider relations contacts at all priority payers within the first 90 days

- Payer-by-payer network strategy and participation methodology documented and approved by leadership within the first six months

- Agreements negotiated and executed in line with the approved network strategy and rate targets

- Net reimbursement improvement for newly contracted or renegotiated payers relative to baseline

- Dollars recovered or accelerated through payer-level escalations, and average time to resolution

- Scorecards delivered on schedule for all priority payers, with validated metric definitions

Required Qualifications

- Bachelor's degree in Healthcare Administration, Finance, Business, or a related field, or equivalent professional experience

- 10+ years of experience in payer relations, managed care contracting, or provider network management on the provider side, with significant experience in anesthesia or another facility-based specialty (emergency medicine, radiology, pathology); anesthesia strongly preferred

- Demonstrated track record of negotiating and closing payer agreements, including rate and contract language negotiation through execution

- In-depth knowledge of how anesthesia contracts are structured, 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, ideally in the Texas market

- 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 in producing supporting models

- Strong negotiation skills and executive presence; able to represent the organization with senior payer contacts and present data-driven recommendations to executives

- Advanced Excel skills; familiarity with business intelligence tools (e.g., Power BI, Tableau, Sigma)

Preferred Qualifications

- Master's degree (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 (e.g., PhyGeneSys)

- HFMA (CRCR), AAPC, or similar certification

Work Environment and Physical Requirements

- On-site position based at the OrthoMed Anesthesia corporate office in Addison, TX, during regular business hours

- Primarily an office setting involving extended periods of computer, telephone, and seated work

- Periodic travel required for payer meetings, negotiations, and industry events

- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the role

Why Join Us

We are a growing anesthesia practice management company with 700+ employees and contractors, committed to supporting healthcare professionals while maintaining a vibrant, collaborative workplace culture. We offer competitive compensation, comprehensive benefits, and genuine opportunities for growth and development.

- Comprehensive health, dental, and vision insurance

- $50,000 company-provided life insurance

- Multiple voluntary insurance options

- Paid holidays and 15 days of PTO

- 401(k) retirement plan with 3% non-discretionary contributions

- Professional development and training opportunities