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[Remote] Senior Provider Network Contractor - Out of Network Provider Negotiations
Note: The job is a remote job and is open to candidates in USA. Healthfirst is a health plan company seeking a Senior Provider Network Contractor responsible for negotiating with out-of-network healthcare providers to secure in-network participation. The role involves high-stakes negotiations, strategic provider engagement, and collaboration with internal teams to improve network adequacy and reduce out-of-network spending.
Responsibilities
- Identify and prioritize high-cost, high-utilization, and strategically critical out-of-network providers and facilities based on claims data, network gaps, and regulatory network adequacy requirements
- Develop and execute targeted outreach strategies to engage providers with significant leverage or market influence
- Serve as the primary point of contact provider practice leadership
- Articulate the health plan’s value proposition, network strategy, and long-term partnership opportunities to prospective in-network providers
- Lead complex, high-stakes negotiations with out-of-network providers to achieve competitive reimbursement rates and favorable contract terms
- Apply advanced knowledge of reimbursement methodologies, including professional fee schedules, DRGs, APCs, per diems, case rates, and alternative payment models, as appropriate
- Leverage market intelligence, benchmarking data, and utilization analytics to support evidence-based negotiation strategies
- Structure agreements that balance provider market realities with the health plan’s financial targets, affordability goals, and regulatory constraints
- Negotiate contract provisions beyond rates, including escalation terms, termination clauses, value-based incentives, and operational requirements
- Partner closely with internal health plan teams, including Finance, Legal, Utilization Management and Operations to ensure alignment with enterprise objectives
- Provide expert guidance and recommendations to health plan leadership on negotiation strategy, market trends, and provider leverage dynamics
- Ensure smooth transition of executed agreements into contract management, credentialing, and claims systems
- Proactively identify and resolve barriers to provider participation and onboarding
- Track and report measurable outcomes, including conversion of out-of-network providers to in-network status, negotiated rate improvements, and reductions in out-of-network spend
- Provide executive-level reporting on negotiation progress, financial impact, and network adequacy improvements
- Maintain thorough documentation of negotiation strategies, outcomes, and contractual terms
Skills
- Bachelor's degree required; advanced degree (MBA, MHA, JD) strongly preferred
- 8–10+ years of progressive experience in managed care contracting and network negotiations within a health plan or comparable payer environment
- Proven track record of leading complex, high-value provider negotiations and securing favorable in-network agreements
- Deep expertise in healthcare reimbursement models, provider economics, and managed care regulatory frameworks
- Strong understanding of provider market consolidation, competitive dynamics, and leverage strategies
- Exceptional negotiation, influence, and executive-level communication skills
- Ability to operate independently with minimal oversight in a contractor or consulting capacity
- Experience negotiating with large health systems, academic medical centers, and highly specialized provider groups
- Demonstrated success reducing out-of-network spend through targeted contracting initiatives
- Familiarity with state and federal network adequacy requirements applicable to health plans (e.g., Medicaid, Medicare Advantage, Commercial)
- Experience supporting or advising executive leadership on managed care strategy
Benefits
- Medical
- Dental and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
Company Overview
