Senior Provider Network Contractor - Out of Network Provider Negotiations

HealthFirst • New York, NY

26d

About The Position

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. Core Responsibilities Strategic Out-of-Network Provider Engagement 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. Advanced Contract Negotiation & Rate Strategy 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. Health Plan Integration & Stakeholder Alignment 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. Performance Management & Reporting 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; 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.

Nice To Haves

• 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.

Responsibilities

• Strategic Out-of-Network Provider Engagement 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.

Benefits

• Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements).

What This Job Offers

• Career Level: Senior