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

This role is a highly specialized negotiator focused on strategically engaging out-of-network healthcare providers and facilities to secure in-network participation at competitive, market-aligned rates for a health plan. The position drives high-impact, complex negotiations 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 for 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.

Preferred Qualifications

• 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.

Pay

Greater New York City Area (NY, NJ, CT residents): $122,900 - $188,020

All Other Locations (within approved locations): $105,100 - $160,480

Benefits

• Medical, dental, and vision coverage.
• Incentive and recognition programs.
• Life insurance.
• 401k contributions.

All benefits are subject to eligibility requirements.