Note: The job is a remote job and is open to candidates in USA. CareFirst BlueCross BlueShield is seeking an experienced Provider Contracting Specialist to lead and manage negotiations for provider-specific contracts. The role involves analyzing financial data, ensuring compliance with regulations, and coordinating with internal teams to transition to value-based care while maintaining relationships with healthcare providers.

Responsibilities

• Contract Development and Negotiation Serves as a consultant and subject matter expert (SME) in contracting and reimbursement, offering insights during contract development and negotiations with smaller provider practices based on claims and market analysis
• Supports negotiations, development of strategy, market and provider intelligence, and contract execution for institutional, ancillary and professional providers, including implementation oversight. Uses claims and code data to draft and negotiate fixed-price and cost reimbursement care contracts
• Evaluates reimbursement inquiries and develops cost-effective and competitive reimbursement strategies, with an emphasis on transitioning from fee-for-service to value-based care
• Reviews the performance of provider partners based on utilization, trends, and quality metrics to develop rate/reimbursement solutions. Ensures that contracts clearly outline responsibility for performance costs, and that profit or fee incentives offered are tailored to the uncertainties involved in contract performance
• Research and Data Analysis Collects, analyzes, and interprets data from internal and external sources (e.g., cost of care, services, codes, market trends) to ensure accuracy and relevance for network partners
• Reviews various healthcare reimbursement methods and projects financial impacts of provider contracts within predetermined targets, summarizing findings using charts, graphs, tables or narratives
• Recruitment and Relationship Responsible for developing and maintaining relationships with contracted healthcare providers across various specialties
• Collaborates with internal teams within Health Services to identify and address gaps in accessibility and network adequacy through recruitment and contracting. Ensures a balanced network composition that is geographically competitive, offers broad access, and meets cost and trend management objectives
• Regulatory and Healthcare Landscape Monitors and remains current on political, legal, compliance and regulatory trends
• Ensures contracts comply with applicable state and federal regulations and guidelines and actively participates in workgroups or legislative committee meetings
• Administration Coordinates administrative tasks 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, ensuring timely and correct payments for services rendered

Skills

• Bachelor's Degree in Business Administration, Healthcare, Public Health, Finance or related field OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience
• 2 years healthcare, business or related field
• 1 year experience in contracting, provider recruitment or provider relations
• Understanding of multiple reimbursement methodologies used in healthcare provider contracting, including third party payment methodologies, delegated arrangements and payor networks (PPO, HMO, value-based contracting, etc.)
• Effective time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals
• Strong interpersonal skills to effectively interface with all levels of staff, providers, vendors, and business-related associates. Ability to lead project teams towards goal attainment and work independently or as part of a team
• 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
• Proficient with financial analysis/modeling and Microsoft Office 365 including Word, Excel, Outlook and Teams
• Strong negotiation and relationship building skills, along with an understanding of contractual documents and the ability to effectively communicate terms to providers
• 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
• Must be eligible to work in the U.S. without Sponsorship
• Master's degree in Business or Healthcare Administration
• Knowledge of healthcare or health insurance payor industry (Medicare, Medicaid, Commercial, DSNP and other payor programs), including legal and regulatory requirements
• Solid understanding of CPT-4, HCPCS, revenue and ICD coding, medical terminology, claims payment, contract negotiations and problem resolution

Benefits

• Comprehensive benefits package
• Various incentive programs/plans
• 401k contribution programs/plans

Company Overview