[Remote] Senior Provider Network Contractor - Out of Network Provider Negotiations

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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

  • Healthfirst is a health insurer providing medical, business, and health insurance services. It was founded in 1993, and is headquartered in New York, New York, USA, with a workforce of 1001-5000 employees. Its website is https://healthfirst.org.

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    Common Interview Questions

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    Educational Qualification

    Candidates Who Have Passed Graduate or its Equivalent from a Recognized Board or University Are Eligible For this recruitment. Kindly check the Official Notification for more qualification details. Notification Link Is Given Below.

    Document Required

    Required Documents for This recruitment: Candidate should have these documents before applying online. Candidates are suggested to read the official notification before applying.

    • Qualification certificate with mark sheets.
    • Passport size photographs.
    • Signature.

    How to Apply

    All the eligible candidates can apply for this job as mentioned below:

    • Read official notification carefully from the official website.
    • Read notification carefully before applying.
    • Fill the application form (link is given below).
    • Attach required documents and passport size photo with signature.
    • Then submit. Done.