CareFirst BlueCross BlueShield · 1 week ago
Senior Provider Contracting Specialist (Hybrid)
Baltimore, MD
Full-time
Hybrid
Mid, Senior Level
$72K/yr - $144K/yr
3+ years expCareFirst BlueCross BlueShield is seeking a Senior Provider Contracting Specialist to lead and manage complex negotiations for provider-specific contracts. The role involves analyzing financial data, ensuring compliance with regulations, and collaborating with various departments to enhance provider relations and transition to value-based care.
Health CareNon ProfitService Industry
No H1B
Responsibilities
Contract Development and Negotiation Serves as a subject matter expert (SME) in contracting and reimbursement, offering insights during contract development and negotiations with large top-tier provider practices based on claims and market analysis including implementation oversight. Mentors other analysts on the use of provider 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
Analyze the performance of provider partners based on utilization, trends, and quality metrics to develop rate/reimbursement solutions. Develops contracts that clearly outline responsibility for performance costs, ensuring that profit or fee incentives offered are tailored to the uncertainties associated with 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 to 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
Training and Development Supports new hire onboarding, training, and mentoring of lower-level analysts
Convert and maintain departmental processes into a comprehensive electronic training resource
Qualification
Required
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
3 years experience in contracting or valued-based contracting negotiations
2 years experience in healthcare, provider recruitment or provider relations
Ability to lead on critical corporate initiatives, projects and programs, and stand-in when supervisor is absent
Strong 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.)
Excellent 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 negotiation and relationship building skills, along with an understanding of contractual documents and the ability to effectively communicate terms to providers
Proficient with financial analysis/modeling and Microsoft Office 365 including Word, Excel, Outlook and Teams
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
Preferred
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
Strong 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
CareFirst BlueCross BlueShield
CareFirst. It’s not just our name. It’s our promise.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Ja'Ron Bridges
Interim President and Chief Executive Officer
Doba Parushev
Vice President, Healthworx Ventures
Recent News
2025-10-02
BCBSM, Inc., dba Blue Cross and Blue Shield of Minnesota
2025-09-09
2025-08-07
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