Payor Relations Specialist

Position Summary

The Payor Relations Specialist is responsible for managing relationships with health insurance payors and ensuring compliance with all contractual agreements. This role requires a detailed understanding of healthcare reimbursement, strong negotiation skills, and excellent communication abilities. The Payor Relations Specialist will serve as the primary point of contact for resolving payor issues, coordinating contract implementation, and monitoring payor performance.

Duties and Responsibilities

• Serve as the primary liaison between the organization and managed care organizations, commercial payors, and governmental payors (e.g., Medicare, Medicaid).
• Independently analyzes and interprets complex contractual and regulatory data to identify systemic compliance failures, developing and implementing strategic corrective action plans to recover maximum revenue.
• Play a key role in the negotiation and renegotiation of payor contracts, determining acceptable reimbursement rates and terms within established parameters, and committing the organization to contract language that significantly impacts the company's financial health and ease of operation.
• Play a key role in the comprehensive implementation strategy for new payor agreements, ensuring alignment across Billing, Credentialing, and Clinical Services.
• Maintain comprehensive, up-to-date documentation of all payor contracts, fee schedules, and correspondence in the designated file system.
• Track key performance indicators (KPIs) related to payor performance, providing regular reports to management on trends and issues.
• Conduct training sessions for internal team members on new contract provisions, billing guidelines, and payor policy changes.
• Attend and represent the organization at payor meetings and industry conferences.
• Address and resolve complex claim issues and appeals that require direct payor intervention, escalating unresolved issues.
• Compliance with Centria's Code of Conduct, policies and procedures, and Federal and State laws.
• Responsibility to report violations of Company policies or the Code of Conduct.

Required Qualifications, Skills, and Knowledge

• Bachelor's degree in Healthcare Administration, Business, or a related field is preferred.
• Minimum of 3 years of experience in payor relations, managed care contracting, medical billing, or a similar role within a healthcare setting.
• Strong knowledge of CPT, ICD-10 coding, and healthcare reimbursement methodologies.
• Proven ability to negotiate and manage complex contracts.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).
• Ability to analyze and interpret complex data and financial reports.
• Ability to follow written instructions
• Ability to use computers and computer/software programs
• Ability to communicate expressively and receptively
• Working knowledge of laptop/desktop PC
• Proficiency in Microsoft Suite (Word, Excel)
• Proficiency in G Suite (Gmail, Drive, Docs, Sheets, Google Meet)