Director, Out-of-Network Contracting

HealthFirst•New York, NY

4d•$127,500 - $236,555

About The Position

The Director, Out-of-Network Contracting will report directly to the VP of Provider Network Strategy and Optimization and will serve as the Company’s central authority for establishing, negotiating, and maintaining Out-of-Network contractual arrangements, with a primary focus on reducing OON spend through disciplined contracting strategies and network expansion opportunities. This role has end-to-end accountability for the development, negotiation, execution, and governance of all OON contractual arrangements, with a mandate to materially reduce OON spend, improve unit cost performance, and expand sustainable network access. The Director will be responsible for developing contracting solutions to address escalated OON unit cost issues and formalizing rate agreements across facility, professional, ancillary, and behavioral health providers. The function will consolidate all OON contracting activities under a single, centralized organization to drive consistency, compliance, and cost efficiency. This role will own the development and maintenance of OON contracting policies, procedures, and rate methodologies, informed by regulatory requirements, market intelligence, and network access needs. The Director will develop efficiencies that reduce reliance on episodic negotiations by converting repeat OON utilization into structured contractual arrangements, including opportunities to transition OON providers into Healthfirst’s contracted network at sustainable rates. The role will establish the long-term contracting vision, operating model, and rate strategy for OON providers, ensuring alignment with regulatory requirements, market dynamics, and Healthfirst’s affordability and access objectives.

Requirements

Bachelor’s Degree from an accredited institution
10+ years of progressive experience in Managed Care contracting, network management, or related payer functions
Deep expertise in healthcare reimbursement methodologies, including Capitation, APR DRG, MS DRG, APGs, APCs, RBRVS, and Per Diems
Demonstrated success leading enterprise-scale OON contracting strategies with significant financial impact
Experience negotiating complex facility, professional, ancillary, and behavioral health contracts
7+ years of people leadership experience, including leading managers and senior professionals
Strong knowledge of Medicare, Medicaid, and Commercial healthcare regulations and reimbursement structures
Proven ability to influence executive stakeholders and lead cross-functional initiatives

Nice To Haves

Master’s Degree (MBA, MHA, MPH, or related field)
Experience owning or materially influencing budgets, forecasts, and savings targets
Track record of leading large-scale transformation or cost optimization initiatives
Familiarity with behavioral health contracting and reimbursement models
Strong executive presence with the ability to represent the organization in high-stakes internal and external settings

Responsibilities

Set the enterprise strategy for Out-of-Network contracting, including rate methodologies, provider segmentation, and conversion strategies to bring high-utilization OON providers into the contracted network
Own accountability for OON contracting financial outcomes, including unit cost reduction, medical cost savings, and mitigation of OON spend
Design and govern the operating model for centralized OON contracting across facility, professional, ancillary, and behavioral health providers
Establish and maintain enterprise policies, procedures, and rate guidelines that ensure consistency, compliance, and scalability and in alignment with regulatory requirements and market conditions
Lead and develop a team responsible for negotiating and executing Out-of-Network contracts
Represent Healthfirst in external-facing negotiations with providers and other stakeholders as required
Partner with Finance and Medical Economics to develop savings targets, forecasts, and performance tracking tied to OON contracting activity
Ensure compliance with Medicare, Medicaid, and Commercial regulatory requirements and proactively mitigate contracting and reimbursement risk
Translate regulatory changes into contracting strategy
Consolidate facility, professional, ancillary, and behavioral health OON contracting functions to drive standardization and medical cost savings
Partner with Provider Data, Medical Economics, and DSE leadership to assess provider access gaps and recommend contracting or network participation strategies
Identify and advance opportunities to transition high-utilization OON providers into contracted status at Healthfirst rates
Oversee OON contracting needs to satisfy regulatory gaps in the network.
Oversee new OON provider request to join the network.
Establish and maintain strong working relationships with Regulatory, Legal, Finance, teams to ensure compliant and enforceable contracting outcomes
Participate in cross-functional forums to assess the contracting impact of OON requests
Lead the end-to-end OON contracting strategy to materially reduce organizational OON spend
Maintain oversight of contract inventory, savings realization and documentation
Develop and present executive-level materials related to OON contracting performance, inventory, savings, and strategic initiatives
Lead and participate in high-stakes provider contract negotiations
Provide daily staff supervision, coaching, mentoring, and performance oversight
Conduct ad hoc analyses to identify root-cause drivers of OON utilization and contracting gaps
Perform additional internal and external duties as assigned
Serve as an advocate for Providers within Healthfirst while balancing affordability, access, and sustainability