Director, Payer Solutions

Title: Director, Payer Solutions
Reports to: VP, Technology
Classification: Director
Location: Boston (Hybrid)
Job description revision number and date: V 2.0; 03/14/2025

Organization Summary:

Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 with 9 health centers and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices across Massachusetts. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

SCO and One Care Summary

The Senior Care Options (SCO) and One Care programs are health plan programs for dually eligible (Medicare and Medicaid) individuals (“duals”) in Massachusetts. SCO serves eligible beneficiaries aged 65 , while One Care serves duals between ages 21-64. These programs are Fully Integrated Dual-Eligible Special Needs Plans (FIDE-SNP) that integrate Medicare and Medicaid benefits, along with additional support for enrollees such as integrated care teams, care managers, social supports, etc.

Massachusetts’ Medicaid (MassHealth) agency recently conducted a procurement for health plans to offer products in these two programs, for a five-year term starting January 1, 2026. C3 submitted a bid and was selected in September 2024.

Job Summary:

The Director of Payer Solutions will provide oversight for all aspects of Claims Payment System (CPS) implementation and ongoing facilitation. This role is responsible for implementing and configuring CPS with the goal of C3 being able to enroll OneCare/SCO members and pay medical, BH and pharmacy claims (FFS and Capitation).

The Director of Payer Solutions will embody a culture of collaboration and high performance to elevate the use of technology at the organization.

Responsibilities:

• As a member of the C3 Management Team, serve as an organizational champion for the company’s work on Diversity, Equity and Racial Justice
• Oversee staffing and implementing policies, procedures, and workflows across the department that is compliant with State and Federal Regulations
• Provide coordination for assigned activities, ensuring all assignments and projects are delivered on- time and within scope
• Manage processes and relationships related to 3rd party technology partners, vendors, tools, and services
• Use critical thinking skills to assist in the definition of project scope and objectives, involving all relevant stakeholders and setting achievable timelines with appropriate interim milestones to mark progress
• Foster collaborative relationships with leaders across clinical, operational, and administrative functions
• Work collaboratively across teams, within the multi-matrixed nature of work environment, to facilitate meeting discussions, engage all relevant stakeholders, and develop useful presentation materials with the goal of advancing and achieving contract deliverables
• Collect and disseminate accurate, relevant and timely information to the members of the select project team or committee
• Participate in staff, management, and provider meetings, as necessary
• Manage a team of analysts working on CPS configuration, Enrollment, and Claims
• Recruit, train, and manage staff to ensure quality of work, meet productivity levels, and completion of task
• Develop a detailed project plan to monitor and track progress; manage changes to project scope and schedule; identify, track, and develop mitigation plans for risks; reports and escalate as needed
• At times, may need to manage external consultants and contractors, helping them adapt to the C3 culture and obtain information/data necessary to successfully complete their assignments
• Other duties as assigned

Required Skills:

• 8 years of Health Plan Operations experience in a leadership role with responsibilities in claims, configuration, and enrollment
• Experience and success in leading large company-wide projects, systems implementations with tight deadlines
• Knowledge of medical claims and major payment methodologies
• Knowledge of common EDI protocols/transactions: 834, 837, 820
• Experience configuring CPS for Medicaid/Medicare claims processing
• Expertise across clinical, back-office and infrastructure technologies supporting healthcare
• Strong communication, presentation, and relationship-building skills
• Strategic thinker with the ability to translate strategy into execution

Desired Other Skills:

• Strong interpersonal skills and negotiating skills Ability to work collaboratively, across the organization, and as part of a team
• Willingness to “roll up sleeves” in a continuous learning and fast-paced environment
• Excellent project management skills and attention to detail
• Familiarity with the MassHealth ACO program
• Familiarity with Federally Qualified Health Centers
• Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:

• Bachelor’s degree or 10 years of highly relevant Health Plan Operations experience
• Advanced degree in Technology, Business or Healthcare Administration is preferred

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **