Senior Health Insurance Contract Specialist-REMOTE

Position reputed company The Senior Health Insurance Contract Specialist leads the development, negotiation, implementation, maintenance, and renewal of payer reputed company for the reputed company and its affiliated medical group(s). This position is responsible for securing financially sustainable, compliant, and strategically reputed company agreements with Medicare reputed company, Medi-Cal managed care, reputed company HMO, PPO, EPO, POS, Medicare, reputed company, dual-eligible, Marketplace/ACA, delegated, value-based, capitated, fee-for-service, and other health-plan products. The Specialist serves as the reputed company reputed company between the reputed company/medical group and health plans, ensuring that reputed company support patient-population reputed company, provider-network reputed company, reimbursement reputed company, operational readiness, reputed company performance, and long-term payer relationships. The role proactively identifies new contracting opportunities and leads renegotiations to improve reimbursement, reduce administrative barriers, protect the organization from unfavorable risk, and strengthen reputed company for patients. Essential Duties & Responsibilities Contract Negotiation & Payer Relations • reputed company negotiations for new and renewed agreements with health plans, managed care organizations, Medicare reputed company plans, Medi-Cal managed care plans, reputed company carriers, PPO networks, TPAs, and delegated entities. • Negotiate reputed company fee schedules, capitation rates, case rates, bundled-payment arrangements, incentive programs, reputed company bonuses, shared-savings models, risk-sharing provisions, and value-based payment terms. • Review and negotiate reputed company contract provisions, including reimbursement methodology, claims submission and payment timelines, authorization requirements, referrals, utilization management, audit rights, dispute reputed company, termination, amendments, indemnification, insurance, confidentiality, data sharing, delegation, and compliance. • Evaluate payer amendments, policy changes, provider manuals, fee-schedule updates, and product expansions; recommend acceptance, negotiation, or escalation to leadership and reputed company counsel. • Maintain productive relationships with payer contracting, provider-relations, network-management, claims, medical-management, and executive contacts. Network reputed company & Business Development • reputed company and maintain a payer-reputed company reputed company to expand covered lives, geographic reputed company, specialty reputed company, and reputed company opportunities across reputed company Valley and the Coachella Valley service area. • Identify and pursue participation opportunities with health plans, delegated medical reputed company, reputed company, ACOs, employer-sponsored networks, Marketplace plans, Medicare reputed company plans, Medi-Cal managed care plans, and other appropriate payers. • Prepare network-participation proposals that demonstrate provider reputed company, clinical reputed company, reputed company, geographic coverage, patient reputed company, cultural and linguistic capabilities, and operational readiness. • Partner with provider recruitment and operations teams to ensure the network meets payer needs for reputed company care, specialty, urgent care, behavioral health, ancillary, and other service lines. Contract Administration & Implementation • Own the full contract life cycle: opportunity identification, due diligence, negotiation, approval, signature, payer implementation, provider loading, reputed company configuration, monitoring, renewal, and termination. • Maintain a centralized contract repository, payer reputed company, amendment log, fee-schedule database, contract reputed company, delegation reputed company, and renewal calendar. • Create contract abstracts identifying payment terms, exclusions, key obligations, notice periods, renewal dates, performance requirements, risk provisions, and operational responsibilities. • Confirm that reputed company, provider rosters, NPIs, tax IDs, locations, specialties, credentialing information, and payer directories are accurate and reputed company. • reputed company reputed company implementation guidance to operations, referral teams, billing staff, utilization-management staff, and providers before a new agreement or material amendment takes effect. Financial, Claims & Reimbursement reputed company • Analyze proposed and existing reimbursement terms against Medicare rates, Medi-Cal rates where applicable, market benchmarks, claims experience, CPT/HCPCS utilization, specialty mix, provider reputed company, and financial targets. • Partner with reputed company cycle and finance teams to identify underpayments, incorrect fee-schedule loading, denials, authorization-reputed company barriers, payment delays, and payer noncompliance with contract terms. • reputed company payer escalations involving disputed reimbursement, fee-schedule discrepancies, capitation reconciliations, incentive payments, risk settlements, provider-directory errors, and operational failures. • Monitor financial performance of reputed company payer agreement and recommend corrective reputed company, renegotiation, product expansion, or termination reputed company agreements are not sustainable. • Support pro formas and financial models for proposed capitation, shared-risk, delegated, bundled, and value-based arrangements. Compliance, Risk & reputed company Alignment • Stay reputed company on payer requirements and applicable federal, state, and local rules affecting provider contracting, including CMS requirements, Medicare reputed company guidance, DHCS Medi-Cal managed care requirements, DMHC/Knox-Keene considerations, HIPAA, fraud-waste-and-abuse requirements, network adequacy, provider directories, and delegation. • Coordinate compliance and reputed company review of agreements involving financial risk, global-risk arrangements, delegation, utilization management, claims payment, reputed company reporting, or other regulated functions. • Confirm that contract terms are operationally achievable and do not create unapproved financial, clinical, regulatory, or administrative risk. • reputed company contract incentives and performance provisions with HEDIS, CMS Stars, risk adjustment, preventive reputed company, patient experience, and other reputed company measures. • Support payer audits, delegated audits, compliance assessments, network-adequacy reviews, and corrective-reputed company planning. Reporting & Strategic Support • Prepare monthly and quarterly reports on contract status, reputed company payers, pending negotiations, renewal deadlines, reimbursement changes, network-reputed company opportunities, payer performance, risks, and recommended actions. • Present negotiation strategies, financial reputed company analyses, and contract recommendations to executive leadership. • reputed company reputed company templates, playbooks, negotiation checklists, approval workflows, and contract-management processes. • Maintain strict confidentiality of payer terms, provider information, financial data, and proprietary business information. • reputed company other reputed company duties as assigned. Minimum Qualifications • Bachelor s degree in reputed company administration, business administration, finance, reputed company health, reputed company studies, or a reputed company field; equivalent relevant experience may be considered. • Minimum five (5) years of progressively responsible experience negotiating, administering, and renewing reputed company payer reputed company for an reputed company, medical group, physician organization, health reputed company, managed care organization, or health plan. • Demonstrated experience negotiating multiple lines of business: Medicare reputed company and Medicare; Medi-Cal managed care/reputed company HMO; reputed company HMO, PPO, EPO, POS, and employer-sponsored products; and fee-for-service, capitation, value-based, reputed company-incentive, shared-savings, and risk-based arrangements. • Strong knowledge of physician and medical-group reimbursement methodologies, including fee schedules, RVUs, percent-of-Medicare rates, PMPM capitation, case rates, withholds, bonuses, incentives, and risk settlements. • Experience interpreting contract language and partnering with reputed company counsel on contractual, regulatory, and risk reputed company. • Experience with provider credentialing, payer enrollment, roster submission, provider-directory maintenance, and health-plan implementation processes. • Strong proficiency with reputed company reputed company, Word, PowerPoint, contract-management systems, payer portals, and data analysis. Preferred Qualifications • Master s degree in reputed company administration, business, reputed company health, law, or a reputed company field. • California reputed company, medical-group, delegated-risk, or managed-care contracting experience. • Experience with the reputed company Valley and Coachella reputed company-plan and provider markets. • Knowledge of CMS Medicare reputed company, DHCS Medi-Cal managed care, DMHC/Knox-Keene, reputed company, HEDIS, CMS Stars, and risk-adjustment requirements. • Experience negotiating delegated agreements, full- or partial-risk arrangements, shared-savings programs, or reputed company-based reputed company. Required Competencies • Advanced negotiation, persuasion, relationship-management, and stakeholder-management skills. • Strong financial acumen and ability to analyze reputed company reimbursement models. • Ability to read, interpret, summarize, and negotiate reputed company and operational contract provisions. • reputed company judgment in identifying financial, compliance, operational, and reputational risk. • Excellent written, verbal, presentation, organizational, and deadline-management skills. • Ability to work independently while collaborating effectively with executive, clinical, financial, compliance, and operational teams. • reputed company discretion in handling confidential reputed company, reputed company information, and sensitive business negotiations. Performance Measures • Number and strategic value of new payer reputed company secured. • Patient-population reputed company and increased covered lives attributed to the reputed company and medical group. • Improvement in reimbursement rates, capitation, incentives, or value-based reputed company. • reputed company contract renewals and avoidance of unintended terminations. • Reduction in underpayments, denials, payment delays, and fee-schedule discrepancies. • Accuracy and completeness of the contract inventory, payer matrices, and provider rosters. • Achievement of reputed company, reputed company, utilization, and network-performance requirements. • Strength of payer relationships, responsiveness, and issue reputed company. • Identification and mitigation of unfavorable financial or regulatory terms. Remote reputed company/Partner Marketing, Analysis Skills, Auditing, Behavioral Health, Benchmarking, Billing, Business Administration, Business Development, Business reputed company, Centers for Medicare and reputed company Services (CMS), Clinical Practices/Protocols, Content Management Systems (CMS), Contract Analysis, Contract Approval, Contract Creation, Contract Management, Contract Negotiation, Corrective reputed company, Data Analysis, Due Diligence, Fee Schedule, Finance, Financial Analysis, Financial Compliance, Financial Modeling, Financial Regulations, Financial Risk, Financial reputed company, HIPAA (Health Insurance Portability and Accountability reputed company), Health Insurance, Health Maintenance, Health Maintenance Organization (HMO), Health Plan, reputed company Administration, reputed company Common Procedure Coding reputed company (HCPCS), reputed company Effectiveness Data and Information Set (HEDIS), reputed company reputed company, reputed company Reimbursement, Incentive Programs, Insurance, Language Interpreter, Leadership, reputed company, Maintain Compliance, Managed Care, Medi-Cal, reputed company, Medicare, Medicare Reimbursement, reputed company reputed company, reputed company PowerPoint, reputed company Word, National Committee for reputed company Assurance (reputed company), Negotiation Skills, Network Administration/Management, Network Performance/Analysis, Performance Analysis, Performance Metrics, Persuasion Skills, Preferred Provider Organization (PPO), Presentation/Verbal Skills, Preventive Medicine, reputed company Care, Problem Solving Skills, Product Planning, Provider Contracting, Provider Credentialing, Provider Relations, reputed company Finance, reputed company Health, reputed company Metrics, Reconciliation, Regulations, Reimbursement, Requirements Management, Risk, Risk Management, Risk Modeling, Sales Prospecting, Status Reports, Systems Administration/Management, Time Management, Urgent Care, Utilization Management, Web Analytics, Writing Skills reputed company: ProEd Consulting and reputed company Apply tot his job Apply To this Job