About Casa Esperanza
Casa Esperanza, Inc. is a bilingual/bicultural behavioral health treatment provider serving Boston and the Merrimack Valley. Our mission is to empower individuals and families to recover from addiction, trauma, mental illness, and other chronic medical conditions; overcome homelessness and discrimination; and achieve health and wellness through comprehensive, integrated care. Casa Esperanza has an operating budget of $15 million and more than $11 million in assets.
Job Summary: The Director of Payer Relations plays a critical role in identifying areas of exposure for Casa Esperanza due to lack of reimbursement for patient services, improving access to care for our high risk, underserved population. In collaboration with the Executive, Evaluation, and Development teams the Director leads efforts to identify reimbursement opportunities that fund currently unfunded or underfunded services, that transition grant funded innovations to sustainable, third-party reimbursement, or that offer new, more efficient payment methodologies that reduce administrative burden and streamline access to care.
The Director will conduct research and collaborate with internal staff as well as external consultants to respond to RFPs, initiate new applications, and draft RFIs and Letters of Interest to MassHealth, Medicaid MCEs, and other third-party payers in an effort to secure new or expanded contracts and rates. The Director will work to negotiate rates that reflect the true cost of Casa’s culturally/linguistically focused, integrated care model and ensure sustainability and scale to meet the demand for Casa’s unique services.
This leadership role will focus on building positive, results-oriented relationships with third-party payers that benefit patients, payers, and Casa as a provider.
Responsibilities:
- Strategic Planning: Develop and execute reimbursement and access strategies that drive our company's growth and success.
- Responsible for providing strategic and operational leadership in the development and execution of all types of payer contracting
- Monitor changes in reimbursement and provider landscape impacting priority areas and translates them into insights and recommendations.
- Market Analysis: Stay ahead of industry trends, identifying opportunities and challenges in the payer landscape to inform strategic decision-making.
- Work with the Development Team to complete annual payer landscape analysis to identify untapped opportunities for reimbursement.
- Work with Executive and Evaluation Teams to crosswalk reimbursement opportunities with patient needs as part of annual budget process.
- Provide analytic support to a variety of project work such as the following:
- Fiscal impacts of rules issued by Medicaid on inpatient, outpatient, clinician fee schedules, and policies.
- Evaluation of the impact on reimbursement of innovative payment structures.
- Utilization data to predict policy impacts and potential business exposures.
- Assessment of payer contract margin performance for the Agency, including analysis of key trend drivers.
- Contracts:
- Initiate new payer relationships and the development of new contracts and to ensure reimbursement for the full spectrum of services needed by Casa patients.
- Lead negotiations to secure favorable reimbursement terms and rates, ensuring the financial health of our organization.
- Oversee payer contracting to ensure favorable terms and conditions, maximize reimbursement rates, and minimize administrative burdens.
- Complete and submit applications for new payers and new lines of business with existing payers.
- Follow up with payers to ensure application is processing with no items needed until active participating status is achieved.
- Rate analysis and modeling: Conducts cost and utilization analysis, applying data from our Evolv health record and billing system, Rippling HRIS, and Sage accounting software to develop rate models for public testimony, payer negotiations, and EOHHS RFIs.
- Relationship Management: Foster positive relationships with key payer organizations, advocating for fair reimbursement and patient access.
- Issue Resolution: Serve as a champion for our Agency, addressing and resolving payer-related challenges promptly and effectively. Work with payer representatives to resolve issues causing delayed contracting or payments.
- Advocacy: Be a voice for change, advocating for policies that support patient access to behavioral health services and equitable reimbursement.
- Collaboration: Work closely with cross-functional teams to ensure alignment and support for payer relations initiatives, driving results collaboratively.
- Value-based Contracts: Support the development of innovative value-based contract structures and payer partnerships to drive mutual success.
- Reporting: Provide senior management with insightful reports on payer relations activities, performance metrics, and market insights.
- Track and analyze performance metrics, outcomes, and feedback related to provider relations and service delivery to identify areas for improvement and implement corrective actions.
- Other additional duties as assigned.
Qualifications:
- Bachelor’s degree
- Minimum of 5 years of experience in payer relations, healthcare reimbursement, or a related field, with a focus on Massachusetts markets.
- Expertise in Eligibility Verification and Authorizations based on payer requirements
- Experience in contract negotiation with Managed Care Organizations
- Two years’ experience working individuals living with co-occurring addiction, mental illness and/or other trauma related disorders
- Strong verbal/written communication
Competencies:
- Proven track record of building and maintaining strong payer relationships, coupled with excellent negotiation and contract management skills.
- Strong analytical abilities with in-depth knowledge of healthcare reimbursement systems, rate modeling/development, and payer requirements.
- Exceptional communication and interpersonal skills, with the ability to collaborate effectively across teams.
- Writing RFPS
- Ability to use existing technology to achieve desired results
- Skilled in implementing and executing tasks effectively, including time management, multi-tasking, and organizing projects and personnel
- Adept at managing time and handling diverse activities within deadlines while ensuring high-quality results.
- Strong organizational skills and attention to detail; ability to follow through
- Capable of performing well under pressure with a professional demeanor, complemented by strong verbal and written communication skills
- Effective in exercising judgement and decision-making, with strong problem-solving abilities
- Possess strong interpersonal skills, including negotiation, active listening, and the ability to handle situations with diplomacy and tact
Work Type: Hybrid, Full-Time
Work Schedule: Monday – Friday, 9am – 5pm
Supervisory Responsibilities: None
Salary Range: $85,000 - $95,000
What We Offer
Casa Esperanza Benefits Package:
- Holiday Pay (12 days per year + 1 floating holiday)
- Paid Time Off (PTO) - 18 days year one, 20.5 days at year 2, 23 days at year 5
- Sick Pay - 10 paid days per year
- Long / Short Term Disability
- Paid by Company Life Insurance
- Health Insurance (Medical Dental, Vison)
- Health Reimbursement Arrangement (HRA)
- FSA/DCA (Flexible Spending Account & Dependent Care)
- ComPsych Guidance Resources - EAP
- Educational Opportunities
- Tuition Remission
- Employee Ticket at Work (Discounts for Entertainment, travel, movies; etc.)
- Career Advancement Opportunities
- Increased Salary for Credentials
- and more....
Physical & Mental Requirements
While performing the duties of this job the employee is regularly required to walk, stoop, kneel, crouch or crawl and talk or hear. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include distance vision, peripheral vision, and depth perception.
At Casa Esperanza, Inc., the health and safety of our people is our number one priority. That’s why all offers of employment are contingent on the candidate showing proof of being fully vaccinated against COVID 19 (currently one dose of the Johnson & Johnson vaccine or two doses of the Pfizer or Moderna vaccine and boosted, when eligible) to pass the pre-employment requirements. Individuals with medical issues or religious beliefs that prevent them from getting the vaccine may request an exemption from the vaccine requirement.
Casa Esperanza’s EEO Statement
Casa Esperanza, Inc. values its diverse workplace and encourages women, people of color, LGBTQIA+ individuals, people with disabilities, members of ethnic minorities, foreign-born residents, older members of society, and others from minority groups and diverse backgrounds to apply.
We recruit, hire, employ, train, promote, and compensate individuals based on job-related qualifications and abilities. Casa Esperanza, Inc also has a longstanding policy of providing a work environment that respects the dignity and worth of each individual and is free from all forms of employment discrimination, including harassment, because of race, color, sex, gender, age, religion or religious creed, national origin, ancestry, citizenship, marital status, sexual orientation, gender identity, gender expression, genetic information, physical or mental disability, military or veteran status, or any other characteristic protected by law. All employees, interns, volunteers and contractors of Casa Esperanza, Inc. are responsible for maintaining a work culture free from discrimination and harassment by treating others with kindness and respect.
Casa Esperanza, Inc. also provides reasonable accommodation to qualified individuals with disabilities or based on a sincerely held religious belief, in accordance with applicable laws. If you need to inquire about an accommodation, or need assistance with completing the application process, please email hr@casaesperanza.org.