Vice President, Payor Relations

Position Summary:

The Vice President Payor Relations is responsible for developing and executing enterprise-wide payer strategy across all hospital and outpatient service lines. This role leads contract negotiations, reimbursement optimization, and value-based initiatives with commercial payers, Medicaid MCOs, Medicare Advantage plans, and government programs.

The VP serves as the primary executive liaison between the organization and payers, ensuring competitive reimbursement and alignment with quality and utilization outcomes.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Develop and execute a national payer strategy across all facilities (IP, PHP, IOP, HCBS, ECT)
• Lead negotiation of inpatient per diem rates, outpatient hospital rates (PHP/IOP, HCBS), special therapies (e.g., ECT, 1-1 services), and value-based/shared savings arrangements/risk-based
• Standardize contracting approach across states while adapting to Medicaid fee-for-service and Medicaid Managed Care contracting and state directed payment programs (SDPs)
• Drive optimization of reimbursement in Medicaid MCO contracts, Medicare Advantage contracts and other state and federal contracts
• Lead the response to RFPs for grant-related contracts, LMHA and CMHC contracts, provider-based relations (CMS 855), and SAM.gov applications and updates
• Partner with finance and policy teams to identify rate inequities and unmet service needs
• Partner with finance and policy teams to support legislative and regulatory advocacy through national, state and local trade associations and advocacy groups
• Ensure compliance with CMS rules (Hospital Rate Transparency, parity, IMD exclusion, etc.), state-specific reimbursement methodologies, and LMHA and CMHC contract requirements

• Support payer-related revenue performance, including net revenue per adjusted patient day and LOS optimization strategies
• Assist the revenue cycle team to analyze denials, underpayments, and contractual requirements, as well as variance between contracted vs paid rates
• Advise on initiatives to improve yield per patient, rate proposal development
• Ensure facilities maintain in-network status with key payers
• Support expansion into new markets by securing contracts for new facilities and service lines, and negotiating go-live rates and interim agreements
• Position organization as high-quality behavioral health partner and solution for ED boarding, readmissions, continuum services and access gaps
• Develop payor partnerships tied to reduced readmissions (7-day / 30-day, all cause readmissions), ED diversion and LOS management, HEDIS measures (e.g., FUH, IET, FUM) and reduction in total cost of care
• Structure bundled payments, case rates, and risk-based or shared savings models

• Align clinical programs (PHP step-down, HCBS integration) with payer priorities
• Collaborate with revenue cycle team on billing, collections, denials
• Collaborate with clinical leadership (Intake, UM, PI/Risk, HIM, Medical Staff, Nursing)
• Collaborate with Business Development (new programs, expansion of existing services, satellite OP, integration with HCBS)
• Collaborate with Health Information Exchange (HIE) participation with IT and HIM
• Provide payer insights into supporting program design (e.g., PHP with boarding), HCBS integration, improving authorization and utilization management processes, and managed care driven policy changes (e.g., ASAM Criteria 4.0, revenue code changes)
• Lead and develop a team of facility-based stakeholders (CEO, CFO, Business Office Directors, Directors of Utilization Management, Clinical Directors) for contract compliance monitoring
• Establish KPIs for contract execution timelines, rate improvement targets and payer performance scorecards
• Perform other duties as assigned.

Safety (15% of performance review)

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports “near misses”, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity (15% of performance review)

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods, as established by job description, policies, or hospital leadership
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences

Education

• Required: Bachelors degree
• Preferred: MBA or MHA
• Maintains education and development appropriate for position.
• May substitute experience for education

Experience

• Required: 10 years in healthcare payor relations with strong experience in managed behavioral health or psychiatric hospitals. Knowledge of Medicaid MCO contracting, IMD reimbursement structures, and Medicare and commercial contracting.
• Preferred: Previous experience with psychiatric hospital systems (IMD and outpatient continuum), state directed payment programs (SDPs, HRIP, CHIRP, ATLIS), PHP/IOP reimbursement strategy, and HCBS contracting
• May substitute education for experience