Provider Contract Manager

Position Description

Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future.

Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA."

This role leads strategic provider partnerships-such as with hospitals, physician groups, and ancillary providers-to negotiate mutually beneficial contracts and support Capital Blue Cross's goals. The individual is accountable for executing contract negotiations, driving provider network strategy, and implementing innovative reimbursement models, including value-based programs and risk arrangements. They ensure contracts align with regulatory, financial, and operational requirements, and present proposals for internal approval.

The role collaborates across internal teams, supports performance programs like STARS and risk adjustment, and represents the contracting unit in internal committees to align business processes with contract strategy and execution.

Responsibilities and Qualifications

* Serves as principal lead on a defined number of providers for negotiation, strategy, and market intelligence. Responsibility may relate to significant provider spend ($200+ million). Must develop a level of trust and credibility with key provider partner representatives and foster a business relationship beneficial to Capital Blue Cross. Provides market intelligence to Capital's leadership and makes recommendations for strategies that appropriately leverage key partnerships.

* Engages with provider partners on financial incentive programs offering additional revenue opportunities and is the primary spokesperson to assigned providers for all medical value initiatives.

* Assists in the establishment of contract-related criteria and contracting guidelines to optimize financial performance and minimize Plan risk. Serves as a key contact providing support for information and education around programs. Lead in acquisition and merger strategies and contract requirement fulfillments for all assigned providers.

* Has oversight and responsibility for the financial, data and statistical analytic needs of the contracting function specific to negotiations. Responsible for communicating analytical needs to appropriate internal staff, including the competitive pricing development of systematic methodologies. Uses unit medical cost strategies to support responsible stewardship of Member and customer healthcare dollars.

* Responsible for understanding provider partners' service needs and incorporating contract solutions to support providers and Capital Blue Cross in reaching shared goals. Responsible for investigating and generating business improvement concepts that may be gained through contracting modification, effort or initiative.

* Directs and manages any necessary special projects affecting networks and health systems. Ensures all appropriate internal departments and constituencies are involved and provides clear communication. Serves as the ongoing contracting area liaison and advisor for any variety of process development and oversight committees, project teams and/or task forces.

Skills:

* Demonstrated ability to negotiate contract language provisions typically found in Provider Agreements for Commercial and Medicare Advantage markets.

* Proven and strong negotiation, written, and verbal skills necessary to communicate with varied audiences on subjects ranging from technical to subjective in nature.

* Proven ability to identify/formulate projects of major importance and scope and follow through conclusion successfully without direct supervision.

* Ability to apply situational negotiation techniques to achieve desired outcomes.

* Ability to interpret and employ data to demonstrate outcomes of proposed negotiation tactics.

* Enhanced ability to develop collaborative relationships through written/verbal communication, both in person and in a virtual environment across the enterprise and with providers.

* Ability to coordinate, prioritize, and organize tasks and schedules to meet and balance priorities and objectives set forth by Director/Sr. Director and the providers. Ability to adapt to changing priorities in a fast-paced environment while working independently with minimal direct supervision.

* Ability to…