Provider Contract Manager

Capital Blue Cross•Harrisburg, PA

1d•Hybrid

About The Position

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” This role leads strategic provider partnerships—such as with hospitals, physician groups, and ancillary providers—to negotiate mutually beneficial contracts and support Capital Blue Cross’s goals. The individual is accountable for executing contract negotiations, driving provider network strategy, and implementing innovative reimbursement models, including value-based programs and risk arrangements. They ensure contracts align with regulatory, financial, and operational requirements, and present proposals for internal approval. The role collaborates across internal teams, supports performance programs like STARS and risk adjustment, and represents the contracting unit in internal committees to align business processes with contract strategy and execution.

Requirements

Demonstrated ability to negotiate contract language provisions typically found in Provider Agreements for Commercial and Medicare Advantage markets.
Proven and strong negotiation, written, and verbal skills necessary to communicate with varied audiences on subjects ranging from technical to subjective in nature.
Proven ability to identify/formulate projects of major importance and scope and follow through conclusion successfully without direct supervision.
Ability to apply situational negotiation techniques to achieve desired outcomes.
Ability to interpret and employ data to demonstrate outcomes of proposed negotiation tactics.
Enhanced ability to develop collaborative relationships through written/verbal communication, both in person and in a virtual environment across the enterprise and with providers.
Ability to coordinate, prioritize, and organize tasks and schedules to meet and balance priorities and objectives set forth by Director/Sr. Director and the providers. Ability to adapt to changing priorities in a fast-paced environment while working independently with minimal direct supervision.
Ability to apply Plan policy and mission to ongoing activities generated by non-traditional occurrences within the provider community. Ability to build and strengthen relationships with providers to help differentiate Capital Blue Cross from competitors.
Demonstrated financial acumen and analytical skills to translate data into action.
Broad knowledge and understanding of the Medicare Program reimbursement methodologies, and Medicare Advantage Programs.
Knowledge of industry provider contracting arrangements and methodologies including reimbursement methods; quality plans and initiatives; provider tiering arrangements.
Knowledge of evolving health care practices and their applicability benefit plan designs and contracting. Knowledge of consumer-oriented plan designs.
Knowledge of the various State and Federal licensing and oversight bodies, existing accreditation organizations (NCQA, AHRQ, JCAH, CARF, etc.) and the various criteria established and being established by such organizations.
Demonstrated attributes for independently leading a provider negotiation and performing as an active team member on inner departmental negotiation strategy development for Hospital, affiliated Health System providers, and/or Accountable Care Organization engagements.
Active team contributor as network contracting lead for cross functional teams engaged in high profile projects involving Corporate Initiative contracting efforts to strategically realign contractual provisions with the fast-paced evolution of market standards.
Demonstrated achievement as a cross-functional team lead on process design, improvement, or project planning activities.
Ability to quickly gain knowledge of new business processes and issues applying effective change plans.
8 years related work experience with at least 5 of those years including direct payer/provider negotiation experience with complex, financially significant relationships between payers, health systems, large independent practices, and/or clinically integrated networks.
Bachelor’s degree in business, finance, healthcare management, clinical/medical science, or a related field.
Possession of valid driver’s license, and willingness to travel frequently within the service area.
While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must be able to work over 40 hours per week. The employee must occasionally lift and/or move up to 5 pounds.

Nice To Haves

Demonstrated ability to coordinate, plan and engage a team in the design of systematic applications of contract provisions in a complex claims processing system preferred.
Preferred strong understanding of Blue Cross Plans.
2 years operational experience with value-based programs (ACO, PCMH, and Bundled Payments) preferred.
Master’s degree preferred.

Responsibilities

Serves as principal lead on a defined number of providers for negotiation, strategy, and market intelligence. Responsibility may relate to significant provider spend ($200+ million). Must develop a level of trust and credibility with key provider partner representatives and foster a business relationship beneficial to Capital Blue Cross. Provides market intelligence to Capital’s leadership and makes recommendations for strategies that appropriately leverage key partnerships.
Engages with provider partners on financial incentive programs offering additional revenue opportunities and is the primary spokesperson to assigned providers for all medical value initiatives.
Assists in the establishment of contract-related criteria and contracting guidelines to optimize financial performance and minimize Plan risk. Serves as a key contact providing support for information and education around programs. Lead in acquisition and merger strategies and contract requirement fulfillments for all assigned providers.
Has oversight and responsibility for the financial, data and statistical analytic needs of the contracting function specific to negotiations. Responsible for communicating analytical needs to appropriate internal staff, including the competitive pricing development of systematic methodologies. Uses unit medical cost strategies to support responsible stewardship of Member and customer healthcare dollars.
Responsible for understanding provider partners’ service needs and incorporating contract solutions to support providers and Capital Blue Cross in reaching shared goals. Responsible for investigating and generating business improvement concepts that may be gained through contracting modification, effort or initiative.
Directs and manages any necessary special projects affecting networks and health systems. Ensures all appropriate internal departments and constituencies are involved and provides clear communication. Serves as the ongoing contracting area liaison and advisor for any variety of process development and oversight committees, project teams and/or task forces.