Provider Operations Contract Negotiator

Job Description

Job Description

Work Schedule : Primarily remote, with occasional regional travel required.

Position Summary :

The Provider Operations Contract Negotiator will play a critical role in managing provider contracting activities and negotiations to ensure the availability of a robust network of healthcare providers for our members. This role will be responsible for negotiating provider contracts, developing provider network agreements, and maintaining positive relationships with contracted providers. The Contract Negotiator will collaborate closely with internal departments, external stakeholders, and legal counsel to negotiate competitive rates, terms, and conditions that align with the organization's strategic goals and objectives.

Essential Duties and Responsibilities :

• Provider Contract Negotiation : Lead negotiations with healthcare providers, including hospitals, physicians, specialists, and ancillary service providers, to secure favorable contract terms, rates, and conditions.
• Contract Development : Develop provider network agreements, amendments, and addendums in collaboration with legal counsel, ensuring compliance with regulatory requirements, Medicaid guidelines, and company policies.
• Rate Setting and Analysis : Conduct market research and analysis to evaluate provider reimbursement rates, fee schedules, and payment methodologies, proposing adjustments as needed to maintain competitiveness and cost-effectiveness.
• Provider Network Expansion : Identify opportunities to expand and enhance the provider network to improve access to care and meet the needs of our members, including but not limited to our Medicaid members, negotiating contracts with new providers as necessary.
• Relationship Management : Cultivate and maintain positive relationships with contracted providers, serving as the primary point of contact for contract-related inquiries, concerns, and issue resolution.
• Contract Compliance : Monitor provider compliance with contract terms and performance metrics, working collaboratively with Provider Operations and Quality Improvement teams to address issues and ensure adherence to contractual obligations.
• Provider Education : Educate providers on contract terms, policies, and procedures, facilitating training sessions and communications to promote understanding and compliance.
• Data Analysis and Reporting : Analyze provider contract performance, utilization patterns, and reimbursement trends to identify opportunities for improvement and inform contract negotiations and decision-making.
• Collaboration : Collaborate with cross-functional teams, including Provider Operations, Network Development, Finance, and Compliance, to align contracting activities with organizational goals and objectives.
• Regulatory Compliance : Stay abreast of regulatory changes, Medicaid guidelines, and healthcare reform initiatives impacting provider contracting, ensuring compliance and timely implementation of required updates.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management .

Qualifications :

Skills and Abilities :

Work Schedule : Primarily remote, with occasional regional travel required.

Physical Demands :

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and / or move up to 15 pounds.

Work Environment :

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside / outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.