Provider Contracting Specialist

Title: Provider Contracting Specialist

Job Type: Full-time

Location: Hybrid 4 days per week in Brighton MA office; 1 day remote from home

FLSA Status: Exempt

Position Summary

This role will facilitate negotiate and maintain agreements with healthcare providers to build networks in support of BrightonOnes health plan. Responsibilities include outreach to institutional ancillary and professional providers to discuss contracting to join the BrightonOne network negotiating contract terms in accordance with Plan design and regulatory requirements reviewing data to evaluate impacts and establishing foundations for long-term network adequacy. This role will also collaborate with various departments and serve as a subject matter expert participate in internal workgroups ensure compliance with contracts and manage standard operating procedures and workflows.

Key Responsibilities

Contract Development and Negotiation

• Supports provider contracting and reimbursement negotiations offering insights and input based on data and market analysis as well as implementation oversight.
• Assesses contract language for compliance with organizational standards and regulatory requirements reviewing revised language with attorneys.
• Evaluates reimbursement inquiries and works with stakeholders to establish competitive reimbursement for both fee-for-service to value-based care models assessing financial impacts against targets.
• Reviews the performance of providers based on utilization trends and quality metrics to inform negotiating priorities.

Provider Recruitment

• Collaborates with internal teams within the organization to identify and address network adequacy through recruitment and contracting.
• Develops and maintains relationships with targeted healthcare providers across various specialties to encourage network participation.
• Creates and refines provider network targets to address network gaps plan enrollment growth and to increase access to care.
• Ensures a balanced network composition that is geographically competitive and offers broad access to meet cost compliance and organizational objectives.

Administration and Compliance

• Ensures contracts comply with applicable regulations guidelines federal program requirements and actively participates in workgroups and coordination with the broader team.
• Monitors and remains current on legal compliance and regulatory trends.
• Proactively coordinates with internal departments to address questions issues and activities related to provider contracts.
• Validates final agreements and amendments to ensure accuracy and inclusion of all negotiated changes and facilitating execution and management of the agreement.

Qualifications

Education & Experience

• Bachelors Degree in Business Administration Healthcare Administration Public Health or a related field. Masters degree preferred.
• 5 or more years of experience in provider contracting or a related field.
• Experience in negotiation and relationship building skills along with an understanding of contractual documents and the ability to effectively communicate terms to providers.
• Knowledge of healthcare or health insurance payor industry (Medicare Medicaid Commercial TRICARE and other payor programs) including legal and regulatory requirements.
• Strong understanding of CPT-4 HCPCS revenue and ICD coding medical terminology claims payment contract negotiations and problem resolution.

Skills & Competencies

• Strong strategic thinking and decision-making abilities in complex and fast-paced environments.
• Exceptional written and verbal communication skills; ability to effectively interface with internal stakeholders and externally with providers vendors and other external stakeholders.
• Strong understanding of health care reimbursement methodologies used in healthcare provider contracting including third party payment methodologies delegated arrangements and payor networks (PPO HMO value-based contracting etc.).
• Excellent time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals.
• Strong analytical problem-solving and critical thinking skills with the ability to use reason to identify problems gather data establish facts draw valid conclusions and develop suitable recommendations to propose and if necessary negotiate with the external parties.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers within set expectations for service excellence.
• Must be able to effectively communicate and provide positive customer service to every internal and external customer including customers who may be demanding or otherwise challenging.

Physical Nature of the Job

Some elements of the job are sedentary but the employee will be required to stand for periods of time or move throughout the campus.

Equal Opportunity Employer Statement

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race color religion sex (including pregnancy gender identity and sexual orientation) national origin age disability genetic information protected veteran status or any other characteristic protected by federal state or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Work Authorization

Candidates must be authorized to work in the United States without sponsorship now or in the future.