Healthfirst Out-of-Network Negotiator in New York, New York


This individual shall serve as the primary point of contact between Healthfirst and participating hospitals and hospital affiliated providers ("Hospital Providers"), as assigned, to represent and advance Healthfirst interests in the hospital provider market as the preferred and ultimately pre|eminent plan through superior customer service and flawless execution of provider engagement strategies. Responsibilities include contract management; consultation on proactive approaches to improve financial, clinical and operational performance; providing education/training regarding company|wide initiatives, new products, regulatory standards, etc., and serving as an advocate for Hospital Providers within Healthfirst.

Act as primary point of contact for the Hospital Providers. This includes addressing operational or contractual issues in a timely manner; identifying proactive ways to improve processes and ensure a mutually beneficial relationship; having a thorough understanding of each Hospital Provider's contract, physician network, business goals and issues as they relate to Healthfirst; meeting regularly with Hospital Providers; conducting business presentations; etc. Superior customer service and network leadership will ensure Hospital Provider issues and needs are responded to in a timely and accurate fashion.

  • Ensure that claims issues are addressed timely and accurately. Conduct root cause analysis of any large claims projects submitted. Identify and address provider set up issues that lead to claims problems. Work proactively with Hospital Providers and other functional departments to identify opportunities for process improvement to reduce the volume of claims projects and other improvements in the healthcare delivery/administrative structure.

  • Manage Hospital Providers with business management oversight through routine evaluation of provider performance measured through core principles including profitability, network adequacy, and membership growth. Work proactively with Financial Analysis team to understand and monitor financial performance of hospitals, including Excess Medical Revenue, Risk Pool Performance, risk adjustment activities, etc. Regularly review all standard financial reports available to Hospital Providers to understand hospital performance and areas of opportunity. Keep abreast of competitor activity, including new reimbursement and marketing strategies.

  • Work closely with Clinical Quality team and Hospital Providers to improve clinical, quality and member satisfaction outcomes. Ensure appropriate reports are available that allow Hospital Providers to better manage their patient population (e.g. rosters, care plans, quality reports, etc.). Ensure that hospitals are submitting encounter data as required and provider data, including but not limited to demographic information, internal set-up codes, etc., are reflected accurately in Healthfirst's systems. Work with Hospital Providers to address Access and Availability issues and create corrective action plans, if applicable.

  • Monitor and assure contract compliance in areas including, but not limited to, reporting obligations, responsiveness to regulatory and Healthfirst inquiries, timely submission and payment of claims, provider file submission, etc. Interpret provisions of existing contracts to support other Healthfirst departments. Create and maintain contract summaries. Ensure contract terms are operationally sound and implemented accurately. Effectively educate and communicate Healthfirst benefits and policies, changes, and potential downstream effects to individual provider practices.

  • Additional duties as assigned.

Minimum Qualifications:

Understanding of various payment methodologies (Ex. APR DRG, MS DRG, APGs, APCs, RBRVS, Per Diems)

  • Working within one or more of the following areas: Managed Care, Network Management, Claims, Patient Accounts,

  • Managed care contracting/negotiation

  • Claims resolution;

  • Managing assignments within tight time frames

  • Critical thinking

  • MS Excel, Word


  • Written/Oral Communication skills

Preferred Qualifications:

  • Bachelor’s Degree

  • Root Cause resolution

  • Cross functional experience in working as a liaison to internal business partners

  • Familiar with reimbursement methodologies for Ancillary and Behavioral Health Services (Ex. SNF, Dialysis, Home Care, Urgent Care, Behavioral Health specialties)

  • Project Management

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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