Out of Network Negotiator

The Out of Network Negotiator negotiates single case agreements with all out of network provider types (i.e Ancillary, Behavioral Health, Hospital, Physician) for services authorized by Utilization Management with a goal of negotiating the most favorable rate for Healthfirst.
The Out of Network Negotiator will service assigned out of network provider accounts which includes addressing providers’ general inquiries and resolving any single case agreement related claims issues.
This role also identifies potential recruitment opportunities with out-of- network providers, based on the department’s established recruitment criteria.
The Out of Network Negotiator participates in audit, reporting and project initiatives, as required.

Duties and Responsibilities:

• Negotiate single case agreements with out-of-network providers according to the established single case agreement process. Meets all performance standards related to timeliness, savings, and responsiveness as detailed in the Department’s Job Aids.
  • Initiates contact with providers regarding proposals, to overcome rate objections and utilize effective and efficient negotiation skills to obtain appropriate reimbursement rates.
  • Reviews counter proposals received and measure counters against established reimbursement rate parameters, plan guidelines and department and plan goals.
• Works with Utilization Management to identify provider redirection opportunities where possible and to address authorization issues related to claims denials.
• Manages assigned out of network provider accounts with timely provision of account services including assistance with demographic or financial inquiries, along with SCA-related claims issues.
• Facilitates claims resolution for any single case agreement-related claims disputes.
• Collaborates with multiple internal departments including Claims, Claims Configuration, PDM, UM and other DSE teams.
• Participates in monthly team audits, reports, and other projects, as needed.
• Handles additional duties as assigned.

Minimum Qualifications:

• High School Diploma or GED Equivalent
• 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 timeframes
• 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 race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 [email protected] 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.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $67,200 - $97,155

• All Other Locations (within approved locations): $59,800 - $88,910

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.