Vice President and Head of Payer Strategy
$220k - $275k
Expert
Master's, MBA, JD
Remote in USA
RemoteRemote position; must reside in the Northeast.
Business & Strategy
About the job
Requirements
- At least 10 years of experience in healthcare payer strategy, network contracting, or health plan partnerships with progressive responsibility.
- At least 5 years in senior leadership roles with direct accountability for payer negotiations, contract performance, or network strategy.
- A proven record of building and leveraging executive-level relationships with UnitedHealthcare, Aetna, Cigna, Anthem/BCBS, Humana, or equivalent Tier 1 payers.
- Direct experience negotiating multi-million-dollar payer contracts with measurable results, such as rate improvements, contract wins, or revenue growth.
- Experience in multi-site healthcare settings such as urgent care, behavioral health, outpatient specialty, or retail healthcare.
- Multi-state contracting experience, including Medicaid managed care, telehealth reimbursement policies, and regional BCBS plans.
- Provider credentialing expertise, including CAQH, payer enrollment processes, and multi-state licensure requirements.
- Strong financial modeling skills, including contract rate analysis, market benchmarking, revenue impact modeling, and value-based care financial risk assessment.
- Comfort with payer analytics, claims data, utilization reports, and contract performance dashboards.
- P&L orientation and demonstrated ability to translate payer strategy into revenue growth, margin improvement, and payer mix optimization.
- Experience designing or negotiating value-based arrangements, such as shared savings, bundled payments, quality incentives, outcomes-based contracts, or population health models.
- Familiarity with clinical quality metrics, including HEDIS, NCQA, patient satisfaction, clinical outcomes, and cost-effectiveness.
- Experience in strategic partnership development beyond traditional contracting, including SDOH collaborations, pilot programs, and innovation initiatives.
- Ability to build credibility with payer C-suites, internal executives, and board members.
- Proven negotiation skills in complex, multi-party situations.
- Strong written, verbal, and presentation skills for executive reporting and board-level updates.
- Ability to lead cross-functionally across Operations, Clinical, Finance, and RCM without direct authority.
Responsibilities
- Own strategic relationships with Tier 1 payers, including UnitedHealthcare, Aetna, Cigna, Anthem/BCBS, and Humana, and serve as executive liaison to payer leadership at the C-suite and senior VP levels.
- Negotiate multi-year rate renewals, expand geographic coverage, and improve contract terms, including facility fees, after-hours differentials, and coding and billing policies.
- Lead escalation management by resolving contract disputes, addressing network adequacy issues, and navigating audit and compliance challenges.
- Translate clinical quality, patient satisfaction, and cost-effectiveness into compelling payer value propositions.
- Analyze rate structures, benchmark against the market, and identify opportunities for rate improvement.
- Align contract strategy with operational footprint, utilization patterns, and market expansion plans in partnership with SVP Urgent Care Operations.
- Accelerate behavioral health payer contracting in New York, New Jersey, and Florida, and lead payer entry into six or more new states over 24 months.
- Negotiate rates, terms, and coverage policies that support financial sustainability, with a target of $200,000–$280,000 revenue per clinical FTE.
- Lead payer credentialing and network inclusion strategy for therapists, psychiatrists, and psychiatric nurse practitioners across multiple states, and drive credentialing cycle time to under 45 days.
- Navigate state-specific contracting landscapes, including Medicaid managed care, state employee health plans, regional commercial payers, and telehealth reimbursement policies.
- Leverage urgent care relationships to unlock behavioral health contracting opportunities using an integrated care value proposition.
- Design and execute a behavioral health payer entry playbook covering market landscaping, contract negotiation sequencing, credentialing project management, and post-contract optimization.
- Evaluate and build value-based care partnerships, including shared savings, bundled payments, quality incentive programs, and outcomes-based contracts.
- Lead strategic payer pilots, including integrated care models, SDOH collaborations, pediatric behavioral health integration, and alternative reimbursement models.
- Design clinical-financial frameworks for value-based arrangements, including quality metrics, financial risk models, and performance monitoring.
- Model upside and downside scenarios for value-based contracts in partnership with Finance and Clinical Leadership.
- Position the organization for emerging payment models, including CMS Innovation Center initiatives, Medicaid value-based purchasing, and payer-provider SDOH collaborations.
- Identify strategic payer partnership opportunities beyond traditional contracting, including data sharing, care coordination platforms, and referral network integrations.
- Build payer performance dashboards tracking contract utilization, revenue per contract, payer mix, claims denial rates, and financial performance by payer.
- Benchmark rates and contract terms against urgent care and behavioral health competitors.
- Lead cross-functional payer governance in partnership with RCM, Finance, and Operations.
- Develop negotiation playbooks, contract templates, and rate benchmarking tools to scale the payer strategy function.
- Build and lead the payer strategy team as the organization scales, including future hires in payer contracting, credentialing, and analytics.
- Drive $15 million–$25 million in cumulative revenue impact through contract optimization, new payer partnerships, and value-based upside.
Desired Qualifications
- Prior experience in a hospital system or urgent care environment.
- Urgent care contracting experience, including reimbursement models, facility fees, and coding and billing policies.
- Behavioral health contracting experience, including therapist and psychiatrist reimbursement, telehealth policies, and outcomes-based contracting.
- Pediatric healthcare experience, including pediatric care models, family-centered care, and pediatric quality metrics.
- MBA, MHA, JD, or equivalent advanced degree in business, healthcare administration, or law.
- Prior consulting experience at top-tier healthcare strategy firms such as McKinsey, Bain, BCG, Accenture, or Navigant/Guidehouse.
- Former health plan experience at UnitedHealthcare, Aetna, Cigna, Anthem, Humana, or a regional health plan in network strategy, provider relations, or medical management.
- CMS or state Medicaid experience, including Medicare Advantage, Medicaid managed care, or public payer programs.
- Telehealth reimbursement expertise, including interstate contracting, evolving telehealth policies, and virtual care reimbursement.
About the company
PM Pediatrics operates a network of pediatric urgent care clinics that stay open year-round with extended hours to treat non-emergency illnesses and injuries outside regular pediatrician hours. Clinics resemble emergency departments with on-site X-ray and lab services, and they offer telemedicine and pediatric behavioral health programs. The focus is exclusively on children, using pediatric specialists and equipment to handle conditions like fractures, asthma, dehydration, and wounds, while also expanding via partnerships and acquisitions. The company's goal is to provide accessible, high-quality acute pediatric care and related services, reducing unnecessary trips to hospital emergency departments.
Company Size
1,001-5,000
Company Stage
Series E
Total Funding
$72.4M
Headquarters
Town of North Hempstead, New York
Founded
2005
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Simplify's Take
What believers are saying
- January 2024 CEO Kevin Trexler gives PM Pediatric Care fresh operating leadership.
- July 2024 Florida acquisition added 10 sites, lifting network reach near 90 locations.
- January 2025 recognition for school health validates behavioral-health expansion beyond urgent care.
What critics are saying
- Florida Medicaid reimbursement fights in 2026 threaten margins for pediatric care providers.
- Pediatrix's 2024 Night Lite divestiture shows urgent care assets stay competitively exposed.
- Scaling nearly 90 locations across 15 states creates operational strain and integration risk.
What makes PM Pediatric Care unique
- Exclusive pediatric-only urgent care across newborns through college-age children.
- Runs 365-day urgent care with on-site X-ray, labs, and telemedicine.
- School Health and behavioral care extend beyond urgent care into districts and families.
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Benefits
- Flexible Work Hours
- Conference Attendance Budget
- Professional Development Budget
- Training Programs