Senior Health Insurance Contract Specialist-REMOTE

Position Summary

The Senior Health Insurance Contract Specialist leads the development, negotiation, implementation, maintenance, and renewal of payer contracts for the IPA and its affiliated medical group(s). This position is responsible for securing financially sustainable, compliant, and strategically aligned agreements with Medicare Advantage, Medi-Cal managed care, commercial HMO, PPO, EPO, POS, Medicare, Medicaid, dual-eligible, Marketplace/ACA, delegated, value-based, capitated, fee-for-service, and other health-plan products.




The Specialist serves as the principal liaison between the IPA/medical group and health plans, ensuring that contracts support patient-population growth, provider-network access, reimbursement integrity, operational readiness, quality 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 access for patients. Essential Duties & Responsibilities Contract Negotiation & Payer Relations

• Lead negotiations for new and renewed agreements with health plans, managed care organizations, Medicare Advantage plans, Medi-Cal managed care plans, commercial carriers, PPO networks, TPAs, and delegated entities.
• Negotiate professional fee schedules, capitation rates, case rates, bundled-payment arrangements, incentive programs, quality bonuses, shared-savings models, risk-sharing provisions, and value-based payment terms.
• Review and negotiate core contract provisions, including reimbursement methodology, claims submission and payment timelines, authorization requirements, referrals, utilization management, audit rights, dispute resolution, 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 legal counsel.
• Maintain productive relationships with payer contracting, provider-relations, network-management, claims, medical-management, and executive contacts.

Network Growth & Business Development

• Develop and maintain a payer-target strategy to expand covered lives, geographic reach, specialty access, and revenue opportunities across Imperial Valley and the Coachella Valley service area.
• Identify and pursue participation opportunities with health plans, delegated medical groups, IPAs, ACOs, employer-sponsored networks, Marketplace plans, Medicare Advantage plans, Medi-Cal managed care plans, and other appropriate payers.
• Prepare network-participation proposals that demonstrate provider capacity, clinical quality, access, geographic coverage, patient outcomes, cultural and linguistic capabilities, and operational readiness.
• Partner with provider recruitment and operations teams to ensure the network meets payer needs for primary 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, system configuration, monitoring, renewal, and termination.
• Maintain a centralized contract repository, payer matrix, amendment log, fee-schedule database, contract summary, delegation matrix, 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 contracts, provider rosters, NPIs, tax IDs, locations, specialties, credentialing information, and payer directories are accurate and timely.
• Provide clear 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 Oversight

• Analyze proposed and existing reimbursement terms against Medicare rates, Medi-Cal rates where applicable, market benchmarks, claims experience, CPT/HCPCS utilization, specialty mix, provider capacity, and financial targets.
• Partner with revenue cycle and finance teams to identify underpayments, incorrect fee-schedule loading, denials, authorization-related barriers, payment delays, and payer noncompliance with contract terms.
• Lead payer escalations involving disputed reimbursement, fee-schedule discrepancies, capitation reconciliations, incentive payments, risk settlements, provider-directory errors, and operational failures.
• Monitor financial performance of each payer agreement and recommend corrective action, renegotiation, product expansion, or termination when agreements are not sustainable.
• Support pro formas and financial models for proposed capitation, shared-risk, delegated, bundled, and value-based arrangements.

Compliance, Risk & Quality Alignment

• Stay current on payer requirements and applicable federal, state, and local rules affecting provider contracting, including CMS requirements, Medicare Advantage 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 legal review of agreements involving financial risk, global-risk arrangements, delegation, utilization management, claims payment, quality reporting, or other regulated functions.
• Confirm that contract terms are operationally achievable and do not create unapproved financial, clinical, regulatory, or administrative risk.
• Align contract incentives and performance provisions with HEDIS, CMS Stars, risk adjustment, preventive care, access, patient experience, and other quality measures.
• Support payer audits, delegated audits, compliance assessments, network-adequacy reviews, and corrective-action planning.

Reporting & Strategic Support

• Prepare monthly and quarterly reports on contract status, active payers, pending negotiations, renewal deadlines, reimbursement changes, network-growth opportunities, payer performance, risks, and recommended actions.
• Present negotiation strategies, financial impact analyses, and contract recommendations to executive leadership.
• Develop standard templates, playbooks, negotiation checklists, approval workflows, and contract-management processes.
• Maintain strict confidentiality of payer terms, provider information, financial data, and proprietary business information.
• Perform other related duties as assigned.

Minimum Qualifications

• Bachelor s degree in healthcare administration, business administration, finance, public health, legal studies, or a related field; equivalent relevant experience may be considered.
• Minimum five (5) years of progressively responsible experience negotiating, administering, and renewing healthcare payer contracts for an IPA, medical group, physician organization, health system, managed care organization, or health plan.
• Demonstrated experience negotiating multiple lines of business: Medicare Advantage and Medicare; Medi-Cal managed care/Medicaid HMO; commercial HMO, PPO, EPO, POS, and employer-sponsored products; and fee-for-service, capitation, value-based, quality-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 legal counsel on contractual, regulatory, and risk matters.
• Experience with provider credentialing, payer enrollment, roster submission, provider-directory maintenance, and health-plan implementation processes.
• Strong proficiency with Microsoft Excel, Word, PowerPoint, contract-management systems, payer portals, and data analysis.

Preferred Qualifications

• Master s degree in healthcare administration, business, public health, law, or a related field.
• California IPA, medical-group, delegated-risk, or managed-care contracting experience.
• Experience with the Imperial Valley and Coachella Valley health-plan and provider markets.
• Knowledge of CMS Medicare Advantage, DHCS Medi-Cal managed care, DMHC/Knox-Keene, NCQA, HEDIS, CMS Stars, and risk-adjustment requirements.
• Experience negotiating delegated agreements, full- or partial-risk arrangements, shared-savings programs, or quality-based contracts.

Required Competencies

• Advanced negotiation, persuasion, relationship-management, and stakeholder-management skills.
• Strong financial acumen and ability to analyze complex reimbursement models.
• Ability to read, interpret, summarize, and negotiate legal and operational contract provisions.
• Sound 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.
• Professional discretion in handling confidential contracts, rate information, and sensitive business negotiations.

Performance Measures

• Number and strategic value of new payer contracts secured.
• Patient-population growth and increased covered lives attributed to the IPA and medical group.
• Improvement in reimbursement rates, capitation, incentives, or value-based revenue.
• Timely 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 quality, access, utilization, and network-performance requirements.
• Strength of payer relationships, responsiveness, and issue resolution.
• Identification and mitigation of unfavorable financial or regulatory terms.