Senior Provider Network Contractor - Out of Network Provider Negotiations

Description and Requirements

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.

• 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.

• 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.

• 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.

• Reduction in out-of-network spend and achievement of targeted savings.
• Number and strategic value of out-of-network providers converted to in-network status.
• Improvement in network adequacy, access, and member disruption metrics.
• Timeliness and effectiveness of contract execution and provider onboarding.