Vice President & Head of Payer Strategy

Job description

It's fun to work in a company where people truly BELIEVE in what they're doing! We're committed to bringing passion and customer focus to the business. Summary **This is a remote position, but must reside in the Northeast** PM Pediatric Care is scaling a behavioral health platform to address the mental health crisis facing children and adolescents. We operate state-based clinical pods across New York, New Jersey, and Florida, with national expansion underway. Over the next 24 months, we are growing from 75K to 150K+ annual visits and $15M to $50M+ in revenue. The VP & Head of Payer Strategy is the enterprise payer strategist and chief negotiator for PM Pediatric Care's Urgent Care and Behavioral Health service lines. This role owns national payer relationships, contract strategy, rate negotiations, multi-state expansion, and value-based partnership development. You will serve as the executive voice to Tier 1 payers, BCBS plans, Medicaid programs, and value-based care organizations. You will operate at the intersection of clinical strategy, financial performance, and market access, translating clinical quality and patient outcomes into payer value propositions, negotiating contracts that balance network inclusion with financial sustainability, and building partnerships that position PM Pediatrics for long-term advantage. Reports to: Chief Commercial Officer. Partners closely with: SVP Operations (Urgent Care and Behavioral Health), VP Clinical Programs, Finance/FP&A, and Revenue Cycle Management. This is a high-visibility executive role with direct exposure to the CEO, Board of Directors, and national payer C-suites. Description Responsibilities National Payer Strategy & Tier 1 Relationship Leadership (Urgent Care) — 40% Own strategic relationships with Tier 1 payers : UnitedHealthcare, Aetna, Cigna, Anthem/BCBS, and Humana; 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/billing policies Lead escalation management: resolve contract disputes, address network adequacy issues, and navigate audit and compliance challenges Translate clinical quality, patient satisfaction, and cost-effectiveness into compelling payer value propositions Analyze rate structures, benchmark against 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 Behavioral Health Contract Expansion & Multi-State Market Entry — 35% Accelerate behavioral health payer contracting in NY, NJ, and FL, and lead payer entry into 6+ new states over 24 months Negotiate rates, terms, and coverage policies that support financial sustainability, with a target of $200K–$280K revenue per clinical FTE Lead payer credentialing and network inclusion strategy for therapists, psychiatrists, and psychiatric NPs across multiple states; 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 Value-Based Care & Strategic Partnership Development — 20% Evaluate and build value-based care partnerships: 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/downside scenarios for value-based contracts in partnership with Finance and Clinical Leadership Position PM Pediatrics for emerging payment models: 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 Payer Analytics, Performance & Cross-Functional Leadership — 5% Build payer performance dashboards tracking contract utilization , revenue per contract, payer mix, claims denial rates, and financial performance by payer Benchmark PM Pediatrics 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 $15M–$25M in cumulative revenue impact through contract optimization, new payer partnerships, and value-based upside Target Compensation: $220,000 - $275,000 The salary/rate range listed here has been provided to comply with local regulations and represents a potential base salary/rate for this role. Please note that actual salaries/rates may vary within this range above or below, depending on experience and location. We look at compensation for each individual and based on experience and qualifications. Qualifications Qualifications Required Payer Strategy & Contracting 10+ years in healthcare payer strategy, network contracting, or health plan partnerships with progressive responsibility 5+ years in senior leadership roles (VP, SVP, or Director-level) with direct accountability for payer negotiations, contract performance, or network strategy Proven track 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: rate improvements, contract wins, revenue growth Multi-Site & Multi-State Healthcare Experience in multi-site healthcare settings: 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 : CAQH, payer enrollment processes, and multi-state licensure requirements Financial & Analytical Skills Strong financial modeling: 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: demonstrated ability to translate payer strategy into revenue growth, margin improvement, and payer mix optimization Value-Based Care & Strategic Partnerships Experience designing or negotiating value-based arrangements: shared savings, bundled payments, quality incentives, outcomes -based contracts, or population health models Familiarity with clinical quality metrics: HEDIS, NCQA, patient satisfaction, clinical outcomes, and cost-effectiveness Strategic partnership development beyond traditional contracting: SDOH collaborations, pilot programs, innovation initiatives Leadership & Communication Executive presence: 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 Preferred Industry Background Urgent care contracting experience: reimbursement models, facility fees, coding/billing policies Behavioral health contracting: therapist/psychiatrist reimbursement, telehealth policies, outcomes-based contracting Pediatric healthcare: pediatric care models, family-centered care, pediatric quality metrics Additional Qualifications MBA, MHA, JD, or equivalent advanced degree in business, healthcare administration, or law Prior consulting experience at top-tier healthcare strategy firms (McKinsey, Bain, BCG, Accenture, 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: Medicare Advantage, Medicaid managed care, or public payer programs Telehealth reimbursement expertise : interstate contracting, evolving telehealth policies, and virtual care reimbursement Compensation: Role Dependent The salary/rate range listed here has been provided to comply with local regulations and represents a potential base salary/rate for this role. Please note that actual salaries/rates may vary within this range above or below, depending on experience and location. We look at compensation for each individual and based on experience and qualifications. EEO Statement PM Pediatric Care is an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, disability status, protected veteran status or any other characteristic protected by law.