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