Senior Provider Network Contractor – Out-of-Network Provider Negotiations

The Senior Provider Network Contractor is a highly specialized negotiator responsible for strategically engaging out-of-network healthcare providers and facilities to secure in-network participation at competitive, market-aligned rates for a health plan. This role is focused on high-impact, complex negotiations intended to reduce out-of-network spend, improve network adequacy, and support affordability and access objectives. The contractor operates with a high degree of autonomy and serves as a subject-matter expert in provider reimbursement, market dynamics, and managed care contracting strategies.

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.

Requirements

Bachelor’s degree required; 8 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.

Nice to have

Advanced degree (MBA, MHA, JD) strongly preferred; 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 (all benefits are subject to eligibility requirements)