Executive Director, Payor Relations 

Job Title: Executive Director, Payor Relations 

Supervisor:  Vice President/CFO 

Qualification: Advanced degree (JD, MBA, MHA) preferred. 10+ years of experience working within commercial health insurers, hospital/health system payor contracting/relations, or a regulatory body with oversight of commercial health insurers. 

Position Overview:  Under the direction of the Vice President/CFO, the Executive Director of Payor Relations works to advance the interests of South Carolina’s hospitals and health systems with commercial payors (including Medicaid managed care and Medicare Advantage) through ensuring an effective working relationship with South Carolina health insurers and developing and implementing strategies to promote patient and provider-friendly contracting and reimbursement policies.  The Executive Director of Payor Relations will coordinate with other SCHA team members to advance the Association’s strategic priorities related to payors. He/she will serve as the lead staff member for the SCHA Payor Advisory Committee (PAC) and all related work groups and subcommittees.  

Essential Functions:  

• Serves as the lead SCHA team member on all matters involving commercial health insurers (including Medicaid managed care and Medicare Advantage), as well as distilling changes within CMS and FFS Medicaid in South Carolina.  

• Advises SCHA’s leadership on payer contracting, network, adequacy, reimbursement, and other policies 

• Facilitates SCHA Committees/Workgroups specific to the managed care and revenue cycle teams for members while maintaining compliance with antitrust requirements.  

• Coordinates and facilitates SCHA Payor Advisory Committee (PAC) meetings while maintaining compliance with antitrust requirements. 

• Coordinates and facilitates additional subcommittees and work groups of the PAC, such as Medicare Advantage, Hyve Payer Scorecard, and Price Transparency. 

• Writes exerts to be published for SCHA members on payor-related matters. 

• Works with the advocacy team to foster and maintain strong working relationships with representatives from South Carolina health insurers and regulatory bodies with oversight over health insurers.  

• Works with the SCHA’s advocacy and policy team to develop legislative and regulatory proposals related to the insurance industry. 

• Represents SCHA and its members on work groups applicable to health insurance and payor issues. 

• Assists with the review of legislation and regulations related to the insurance industry, advises the advocacy and policy team during General Assembly sessions (and as otherwise appropriate and necessary), and assists with the development of collateral materials related thereto. 

• Performs the role of SCHA lead for all functions related to the payor scorecard initiative, including analyses for members and facilitating a scorecard user group. 

• Primary lead for reviewing all DataGen reports that are finance leaning and assess whether they should be distributed internally/externally. 

• Coordinates with SCHA’s VP of Advocacy and others on matters before the SC Department of Insurance.  

• Monitors national trends in payor contracting, network adequacy, reimbursement, and other policies to anticipate potential future matters to address in South Carolina 

• Evaluate reimbursement/clinical and administrative policies to interpret potential impact. 

• Send alerts for time sensitive/exceptionally egregious polices 

• Represents SCHA on multi-state state hospital association and national hospital association workgroups and at other meetings related to health insurers and payor policies. 

• From time to time, supervises outside contractors that are engaged to assist with payor-related matters. 

• Supports, organizes, and manages rapidly changing priorities and crisis situations in a focused and professional manner.  

• Executes other duties assigned by the CFO and VP of Advocacy. 

Send resumes and any questions to Michelle Edenfield at medenfield@scha.org.