[Hiring] Provider Contract Manager @Capital Blue Cross

Role Description

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.

• Serves as principal lead on a defined number of providers for negotiation, strategy, and market intelligence.
• Develops trust and credibility with key provider partner representatives.
• Provides market intelligence to Capital’s leadership and makes recommendations for strategies that leverage key partnerships.
• Engages with provider partners on financial incentive programs offering additional revenue opportunities.
• Assists in establishing 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.
• Leads 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.
• 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.
• Directs and manages any necessary special projects affecting networks and health systems.
• Serves as the ongoing contracting area liaison and advisor for various committees and project teams.

Qualifications

• 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.
• Proven ability to identify/formulate projects of major importance and scope.
• 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 communication.
• Ability to coordinate, prioritize, and organize tasks and schedules.
• Ability to adapt to changing priorities in a fast-paced environment.
• Ability to apply Plan policy and mission to ongoing activities.
• Demonstrated ability to coordinate, plan and engage a team in the design of systematic applications of contract provisions.
• Demonstrated financial acumen and analytical skills to translate data into action.

Requirements

• Broad knowledge and understanding of the Medicare Program reimbursement methodologies, and Medicare Advantage Programs.
• Knowledge of industry provider contracting arrangements and methodologies.
• Knowledge of evolving health care practices and their applicability to benefit plan designs and contracting.
• Knowledge of various State and Federal licensing and oversight bodies.
• Preferred strong understanding of Blue Cross Plans.
• Demonstrated attributes for independently leading a provider negotiation.
• Active team contributor as network contracting lead for cross-functional teams.
• Demonstrated achievement as a cross-functional team lead on process design, improvement, or project planning activities.
• Ability to quickly gain knowledge of new business processes and issues.

Experience

• 8 years related work experience with at least 5 years including direct payer/provider negotiation experience.
• 2 years operational experience with value-based programs (ACO, PCMH, and Bundled Payments) preferred.

Education and Certifications

• Bachelor’s Degree in business, finance, healthcare management, clinical/medical science, or a related field.
• Master’s degree preferred.
• Possession of valid driver’s license, and willingness to travel frequently within the service area.

Physical Demands

• Frequently required to sit, use hands and fingers, talk, hear, and see.
• Must be able to work over 40 hours per week.
• Occasionally lift and/or move up to 5 pounds.

Benefits

• Comprehensive benefits package including Medical, Dental & Vision coverage.
• Retirement Plan.
• Generous time off including Paid Time Off, Holidays, and Volunteer time off.
• Incentive Plan.
• Tuition Reimbursement.