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 BrightonOne’s 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.