Job Description

Position Summary

The Payer Contract Specialist is responsible for supporting the negotiation, implementation, and management of payer contracts to ensure optimal reimbursement and compliance. This role analyzes contract terms, evaluates reimbursement methodologies, monitors payer performance, and collaborates with internal stakeholders to ensure accurate interpretation and execution of payer agreements.

Essential Duties and Responsibilities

Contract Development & Negotiation – These responsibilities performed in conjunction with Chief Compliance Officer/General Counsel

• Establish or renew contracts under new Tax IDs as needed.
• Create and maintain contract summary forms for all clients
• Monitor contract termination dates and coordinate timely renewals, renegotiations, or terminations in alignment with client directives.
• Process contract terminations.
• Ensure all payer contracts and related documents, including but not limited to new agreements, notices, amendments and terminations, are maintained following company file storage protocols
• Gather and analyze data to support negotiation strategy, rate improvements, alternate payment models and other opportunities for revenue cycle improvements.
• Assist with the preparation and review of payer contracts, amendments, and fee schedules.

Payer Contract Module Ownership

Serve as the Owner/Subject Matter Expert for the payer contract module in Athena.

• Maintain comprehensive knowledge of the Payer Contract Module (client- and payer-specific), including:
• Initial fee schedule uploads and ongoing maintenance (commercial and governmental).
• Creation and configuration of rule-based logic.
• Daily monitor variance reporting to identify needs for additional or updated rules, flag emerging payer trends, and escalate inappropriate payer behavior to leadership (such as underpayments)

Payer Policy Monitoring & Analysis

• In conjunction with Chief Compliance Officer/General Counsel, monitor, interpret, and communicate payer policy updates, coverage determinations, and regulatory changes to cross-functional teams, ensuring alignment with internal processes.
• Prior to contract expiration, review payer behavior, utilizing analytical tools (e.g., Impact Analysis Report) to recommend revised rates and support negotiation efforts to maximize revenue reimbursement for clients.
• Prepare reports and dashboards that summarize contract metrics and financial outcomes as needed

Internal & External Collaboration

• Participate in monthly or quarterly client meetings as a subject matter expert, offering insights into contract performance, opportunities for improvement, and recommended changes.
• Notify client managers of contracts approaching renegotiation or termination windows.
• Build and maintain positive relationships with payer Provider Representatives.
• Attend key industry conferences and networking events.
• Participate in team meetings to address issues related to payment terms, underpayments, and emerging contract-related trends.
• Partner with revenue cycle teams to resolve contract-related payment issues and if necessary, to assist with appeals or reconsiderations for underpaid or denied claims
• Provide guidance on contract interpretation to internal departments, including coding, billing, and patient access.
• Work closely with legal, compliance, operations, and clinical departments during contract execution and renewals.
• Communicate contract updates and reimbursement changes to key stakeholders.
• Support implementation of new payer programs, reimbursement models, or operational changes.

Requirements

Knowledge, Skills, & Abilities

• Intermediate skills in Microsoft Outlook, Excel, PowerPoint and Word.
• Proficient with Adobe
• Effective written and verbal communication skills.
• Experience with Laserfiche (document storage) preferred but not required.
• Knowledge of healthcare payer contracting, including commercial and government payers (Medicare, Medicaid, managed care)
• Knowledge of payer contract terms, fee schedules, amendments, notices, and termination provisions.
• Knowledge of payer policies, coverage determinations, and regulatory requirements affecting reimbursement.
• Knowledge of data analysis and financial reporting related to contract performance and payer behavior.
• Experience with revenue cycle operations, including billing, coding, payment posting, underpayment analysis, clearinghouse, and appeals.
• Working knowledge of practice management or EHR systems, preferably Athena IDX, payer contract modules.
• Familiarity or experience with Payer Price or similar payer rate transparency tool.
• Proven track record of successful payer contracting negotiations.
• Ability to analyze, evaluate, and apply knowledge of market and healthcare trends to effectively convey the value of a contract.

Education & Experience Requirements

• Bachelor's degree in a related field such as healthcare administration or business preferred.
• 3–5 years of experience in revenue cycle management, managed care, or a related healthcare financial role, with 2 + years’ experience healthcare payer contracting.

Travel

As this is a role that covers the entire corporation, travel may include trips within the US and overnight travel should be expected. Travel expectations would be 10-15% of the time client visits, conferences, and other industry-related events.