VP, Payer Relations

JOB SUMMARY:

ESSENTIAL JOB FUNCTIONS (other duties as required):

Adherence to applicable laws, regulations, and contractual obligations. Follows the principles of the Compliance Program as well as the US Eye Code of Conduct. 

• Develop and execute a comprehensive payer-relations strategy that aligns with the organization’s clinical, operational, and financial goals.
• Advise executive leadership on payer trends, reimbursement risks, contracting opportunities, and market developments.
• Establish priorities for payer negotiations based on reimbursement performance, patient access, geographic expansion, service-line growth, and organizational needs.
• Evaluate the financial and operational impact of payer policies, contract terms, and reimbursement changes.
• Support strategic planning for new practice locations, physician groups, ambulatory surgery centers, and other affiliated services.
• Represent the organization in executive-level discussions with health plans and other payer partners.

• Lead negotiations for commercial, Medicare Advantage, managed Medicaid, and other applicable payer agreements.
• Evaluate contract terms, reimbursement methodologies, fee schedules, payment policies, network requirements, and administrative provisions.
• Partner with Finance and Revenue Cycle leadership to model the financial impact of proposed agreements and contract amendments.
• Ensure contracts support appropriate reimbursement for ophthalmology services, including office visits, diagnostic testing, procedures, surgical services, and specialty care.
• Maintain a centralized process for monitoring contract terms, renewal dates, amendments, notice periods, and key obligations.
• Identify opportunities to improve reimbursement, strengthen contract language, and reduce administrative burden.
• Coordinate with legal counsel as appropriate when reviewing or negotiating agreements.

• Build and maintain productive relationships with payer executives, provider-relations representatives, contracting teams, and medical-management leaders.
• Serve as an escalation point for high-impact payer issues affecting reimbursement, patient access, claims processing, prior authorization, or provider participation.
• Conduct regular payer meetings and business reviews to address performance, policy changes, operational concerns, and opportunities for collaboration.
• Promote timely communication between payers and internal stakeholders.
• Develop strategies to strengthen payer partnerships while protecting the organization’s financial and operational interests.

• Partner with Finance and Revenue Cycle teams to monitor reimbursement trends, payer performance, denials, payment accuracy, and contract compliance.
• Analyze reimbursement by payer, service line, provider, location, and procedure category to identify opportunities and risks.
• Support the development of reporting tools and dashboards that provide visibility into payer performance.
• Identify underpayments, payment variances, and systemic reimbursement issues requiring payer escalation or corrective action.
• Develop strategies to improve net revenue, reduce payment delays, and address unfavorable reimbursement trends.
• Assess the potential impact of proposed payer policy changes and recommend appropriate organizational responses.

• Evaluate payer network-participation opportunities based on patient access, market presence, reimbursement, administrative requirements, and strategic value.
• Support the organization’s participation in payer networks that align with growth plans and patient-care objectives.
• Monitor network status and help address issues that may affect patient access or provider directory accuracy.
• Partner with Credentialing and Provider Enrollment teams to promote timely payer enrollment and accurate participation records.
• Coordinate payer-relations activities related to physician onboarding, practice acquisitions, new locations, and service expansions.

• Collaborate with Revenue Cycle, Finance, Operations, Credentialing, Compliance, Legal, Clinical Leadership, and Information Technology teams.
• Translate contract requirements and payer policies into clear guidance for operational teams.
• Partner with practice leaders to identify payer-related barriers affecting scheduling, patient access, authorizations, claims, or collections.
• Provide education and updates to leadership regarding material payer changes and emerging issues.
• Support due diligence and integration planning for organizational growth initiatives, including acquisitions and new market entry.

• Maintain knowledge of healthcare reimbursement trends, payer policies, managed-care practices, and applicable regulatory developments.
• Monitor changes that may affect ophthalmology reimbursement, ambulatory surgery center payments, prior authorization requirements, and patient access.
• Partner with Compliance and legal counsel to support adherence to applicable laws, regulations, contractual obligations, and organizational policies.
• Maintain appropriate confidentiality and professional discretion when handling sensitive business information.

• Lead, develop, and support payer-relations team members and other assigned staff.
• Establish goals, performance measures, workflows, and accountability standards.
• Foster a collaborative culture focused on data-informed decision-making, timely follow-up, and continuous improvement.
• Promote effective communication across departments and ensure payer-related initiatives remain aligned with organizational priorities.

COMPETENCIES:

• Demonstrated ability to follow oral and written instructions.
• Demonstrated knowledge of material, methods, instruments and equipment.
• Demonstrated ability to read, write and perform mathematical calculations.
• Ability to multi-task, work in a fast-paced environment and manage time accordingly to meet deadlines and requirements of the organization.
• Advanced knowledge of payer contracting, managed-care principles, reimbursement structures, and healthcare financial analysis.
• Strong negotiation skills with the ability to build productive relationships while advocating for organizational priorities.
• Ability to evaluate complex data and translate findings into practical business recommendations.
• Strong executive presence and the ability to communicate effectively with physicians, senior leaders, payer representatives, and cross-functional teams.
• Excellent judgment, analytical thinking, and problem-solving skills.
• Ability to manage multiple priorities, deadlines, and negotiations in a fast-paced healthcare environment.
• Strong written, verbal, and presentation skills.
• High level of professionalism, discretion, and integrity when handling confidential financial and contractual information.
• Proficiency with Microsoft Office applications and the ability to work with contract-management, reporting, and analytics tools.

SUPERVISORY RESPONSIBILITIES:

Travel is required.

REQUIRED EDUCATION AND EXPERIENCE:

• Bachelor’s degree in healthcare administration, business administration, finance, economics, or a related field required.
• Eight or more years of progressive experience in payer relations, managed-care contracting, reimbursement strategy, healthcare finance, revenue cycle, or a related field.

·Demonstrated ability to interpret complex contract language, fee schedules, reimbursement methodologies, and payer policies.

PREFERRED EDUCATION AND EXPERIENCE:

• Master’s degree in business administration, healthcare administration, or a related field preferred.
• Five or more years of leadership experience preferred.
• Experience negotiating payer contracts for a multi-location medical practice, specialty physician group, ambulatory surgery center organization, or healthcare system strongly preferred.
• Experience with ophthalmology, optometry, surgical services, or specialty healthcare reimbursement is highly desirable.