Role Summary
The Director of Managed Care & Payor Strategy is the primary architect of our reimbursement and contracting ecosystem. This role is responsible for the full lifecycle of payer relationships, from initial fee schedule analysis and modeling to high-level negotiations and contract maintenance. You will ensure that our physician partners receive accurate, fair, and timely reimbursement for high-cost biologic therapies. This position sits at the intersection of Finance, Legal, and Clinical Operations, requiring a "data-detective" mindset and a sophisticated understanding of "Buy-and-Bill" economics.
Primary Duties and Responsibilities
- Lead or support negotiations with national and regional commercial payors to secure favorable reimbursement rates for infusion services and specialty drugs.
- Build and maintain complex "Buy-and-Bill" models to analyze the "spread" between drug acquisition costs (ASP/WAC) and payor fee schedules.
- Develop and maintain a comprehensive database of contract terms, carve-outs, and escalators for use by internal billing and revenue cycle teams.
- Perform routine audits of claim data to identify systemic underpayments, contract discrepancies, or unfavorable policy shifts.
- Monitor and combat payor policies that threaten the in-office infusion model, such as "white-bagging" mandates or "alternative funding" programs.
- Translate complex reimbursement data into actionable insights for physician owners and executive leadership.
- Ensure all newly executed contracts are accurately loaded into internal systems and that clinical/billing teams are educated on specific payor requirements.
Required Qualifications
- Experience: 7+ years in managed care contracting, payor relations, or healthcare finance.
- Specialty Knowledge: Minimum 5 years of experience specifically within high-cost outpatient services (e.g., Infusion, Oncology, Specialty Pharmacy, or Biologics).
- Financial Literacy: Advanced proficiency in Microsoft Excel is required, including the ability to model "what-if" scenarios regarding reimbursement shifts.
- Technical Expertise: Strong understanding of HCPCS (J-codes), CPT codes, and the difference between Medical and Pharmacy benefit structures.
- Education: Bachelor’s degree in Healthcare Administration, Finance, or a related field; Master’s (MHA/MBA) preferred.
Preferred Skills
- Direct experience with Buy-and-Bill reimbursement dynamics.
- Knowledge of GPO (Group Purchasing Organization) pricing and its impact on net-reimbursement.
- Proven track record of successfully negotiating with "Big 5" payors (United, Aetna, Cigna, BCBS, Humana).
- Ability to manage a large portfolio of contracts across multiple states or diverse physician specialties.
Medix is committed to advocating for the individual and against all forms of discrimination. We promote equal opportunity in the recruitment and selection process and adhere to all federal and state laws regarding employment. Our goal is to provide employment opportunities solely based on qualifications, skills, and experience relevant to the position.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
*As a job position within our Revenue Cycle division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, handling financial and other payment data, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
