About this opportunity
PM Pediatrics lists this Vice President & Head of Payer Strategy opportunity in workfromhome, New York. Review the employer’s description below for duties, qualifications and application requirements.
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****Prior experience in a hospital system or urgent care environment is strongly preferred**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.DescriptionResponsibilitiesNational 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 levelsNegotiate multi-year rate renewals, expand geographic coverage, and improve contract terms including facility fees, after-hours differentials, and coding/billing policiesLead escalation management: resolve contract disputes, address network adequacy issues, and navigate audit and compliance challengesTranslate clinical quality, patient satisfaction, and cost-effectiveness into compelling payer value propositionsAnalyze rate structures, benchmark against market, and identify opportunities for rate improvementAlign contract strategy with operational footprint, utilization patterns, and market expansion plans in partnership with SVP Urgent Care OperationsBehavioral 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 monthsNegotiate rates, terms, and coverage policies that support financial sustainability, with a target of $200K–$280K revenue per clinical FTELead payer credentialing and network inclusion strategy for therapists, psychiatrists, and psychiatric NPs across multiple states; drive credentialing cycle time to under 45 daysNavigate state-specific contracting landscapes including Medicaid managed care, state employee health plans, regional commercial payers, and telehealth reimbursement policiesLeverage urgent care relationships to unlock behavioral health contracting opportunities using an integrated care value propositionDesign and execute a behavioral health payer entry playbook covering market landscaping, contract negotiation sequencing, credentialing project management, and post-contract optimizationValue-Based Care & Strategic Partnership Development — 20%Evaluate and build value-based care partnerships: shared savings, bundled payments, quality incentive programs, and outcomes-based contractsLead strategic payer pilots including integrated care models, SDOH collaborations, pediatric behavioral health integration, and alternative reimbursement modelsDesign clinical-financial frameworks for value-based arrangements, including quality metrics, financial risk models, and performance monitoringModel upside/downside scenarios for value-based contracts in partnership with Finance and Clinical LeadershipPosition PM Pediatrics for emerging payment models: CMS Innovation Center initiatives, Medicaid value-based purchasing, and payer-provider SDOH collaborationsIdentify strategic payer partnership opportunities beyond traditional contracting, including data sharing, care coordination platforms, and referral network integrationsPayer 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 payerBenchmark PM Pediatrics rates and contract terms against urgent care and behavioral health competitorsLead cross-functional payer governance in partnership with RCM, Finance, and OperationsDevelop negotiation playbooks, contract templates, and rate benchmarking tools to scale the payer strategy functionBuild and lead the payer strategy team as the organization scales, including future hires in payer contracting, credentialing, and analyticsDrive $15M–$25M in cumulative revenue impact through contract optimization, new payer partnerships, and value-based upsideTarget Compensation: $220,000 - $275,000The 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.QualificationsQualificationsRequiredPayer Strategy & Contracting10+ years in healthcare payer strategy, network contracting, or health plan partnerships with progressive responsibility5+ years in senior leadership roles (VP, SVP, or Director-level) with direct accountability for payer negotiations, contract performance, or network strategyProven track record of building and leveraging executive-level relationships with UnitedHealthcare, Aetna, Cigna, Anthem/BCBS, Humana, or equivalent Tier 1 payersDirect experience negotiating multi-million dollar payer contracts with measurable results: rate improvements, contract wins, revenue growthMulti-Site & Multi-State HealthcareExperience in multi-site healthcare settings: urgent care, behavioral health, outpatient specialty, or retail healthcareMulti-state contracting experience including Medicaid managed care, telehealth reimbursement policies, and regional BCBS plansProvider credentialing expertise: CAQH, payer enrollment processes, and multi-state licensure requirementsFinancial & Analytical SkillsStrong financial modeling: contract rate analysis, market benchmarking, revenue impact modeling, and value-based care financial risk assessmentComfort with payer analytics, claims data, utilization reports, and contract performance dashboardsP&L orientation: demonstrated ability to translate payer strategy into revenue growth, margin improvement, and payer mix optimizationValue-Based Care & Strategic PartnershipsExperience designing or negotiating value-based arrangements: shared savings, bundled payments, quality incentives, outcomes-based contracts, or population health modelsFamiliarity with clinical quality metrics: HEDIS, NCQA, patient satisfaction, clinical outcomes, and cost-effectivenessStrategic partnership development beyond traditional contracting: SDOH collaborations, pilot programs, innovation initiativesLeadership & CommunicationExecutive presence: ability to build credibility with payer C-suites, internal executives, and board membersProven negotiation skills in complex, multi-party situationsStrong written, verbal, and presentation skills for executive reporting and board-level updatesAbility to lead cross-functionally across Operations, Clinical, Finance, and RCM without direct authorityPreferredIndustry BackgroundUrgent care contracting experience: reimbursement models, facility fees, coding/billing policiesBehavioral health contracting: therapist/psychiatrist reimbursement, telehealth policies, outcomes-based contractingPediatric healthcare: pediatric care models, family-centered care, pediatric quality metricsAdditional QualificationsMBA, MHA, JD, or equivalent advanced degree in business, healthcare administration, or lawPrior 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 managementCMS or state Medicaid experience: Medicare Advantage, Medicaid managed care, or public payer programsTelehealth reimbursement expertise: interstate contracting, evolving telehealth policies, and virtual care reimbursementCompensation:Role DependentThe 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 StatementPM 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.
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