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Pittsburgh, PA 15222 Penn Avenue Place Company: Highmark Inc.
Job Description
JOB SUMMARY
This position works within a matrixed environment to create the organizations assigned business network strategy, government commercial, etc. Leads all aspects of provider network strategy, including but not limited to:
• Discounts analysis • Competitive analysis • Access analysis • Network operations • Cost savings initiatives • Pay for Value (P4V) initiatives
Supports executive decision makers with analysis related to reimbursement and unit cost management. Oversees the entire business contracting paradigm, including coordination with various departments, and leading the negotiation for the contracting team. Establishes a provider recruitment plan for expansion, new product support, and overall network re-contracting.
Accountable for monitoring recruitment to ensure compliance with program contractual network adequacy standards and coordinates with other departments to ensure the provider network meets the healthcare needs of plan members. Oversees the development of provider contracts to ensure compliance with state-specific requirements.
ESSENTIAL RESPONSIBILITIES
Performs management responsibilities, including but not limited to:
• Involved in hiring and termination decisions • Coaching and development • Rewards and recognition • Performance management • Staff productivity
Plans, organizes, staffs, directs, and controls the day-to-day operations of the department. Develops and implements policies and programs as necessary, may have budgetary responsibility and authority.
Creates the assigned business network strategy relative to network access. Ensures that equitable rates are negotiated for all providers and that provider agreements are in place that appropriately reflect the relationship. Works to ensure that all healthcare costs control mechanisms are fully implemented and executed.
Provides input and leadership for the design and implementation of strategic reimbursement-related activities. Collaborates with other network development staff and external consultants in the development of provider networks across expansion markets. Performs periodic analyses of the provider network from a cost coverage and growth perspective.
Provides valuable input into evaluating opportunities to expand or change the network to meet the business goals and objectives. Performs analysis of claim trend data and/or market information to derive conclusions to support contract negotiations. Conducts periodic review of provider contracting rates to ensure strategic focus is on target with organizational strategy.
Supports market expansion and program activities by leading provider contract analysis and network development related to due diligence.
Other duties as assigned or requested.
REQUIRED EDUCATION
• Bachelors Degree - Business Administration, Healthcare Administration, or related field, or relevant experience and/or education as determined by the company in lieu of a bachelors degree.
PREFERRED EDUCATION
• Masters Degree - Business Administration, Healthcare Administration, or related field.
EXPERIENCE
• Minimum 7-10 years of experience in managed care network development and provider relations, contracting management in a healthcare and/or managed care environment. • 7-10 years of experience in healthcare administration, financing, delivery, or a related field. • 5-7 years of increasingly responsible management positions. • Prior experience negotiating large-scale provider contracts.
KNOWLEDGE SKILLS & ABILITIES
• Complete understanding of all reimbursement methodologies used across the healthcare continuum, e.g., of charge DRG APC. • Ability to effectively communicate and negotiate with C-suite level representatives of hospitals and health systems. • Critical thinking and decision making.
REQUIRED LICENSURE
None.
PREFERRED LICENSURE
None.
TRAVEL REQUIREMENT
50-75% of the time.
LANGUAGE REQUIREMENT
Other than English, none.
PHYSICAL MENTAL DEMANDS AND WORKING CONDITIONS
Position Type: Office-Based
An employee in this position works in an office environment. The position frequently requires the employee to communicate effectively with others both inside and outside the workplace, e.g., in person, via telephone, via email. The employee must be able to understand, interpret, and analyze data, solve problems, concentrate, and research using available technological resources and systems, e.g., computers and computer programs, multi-task, prioritize, and meet multiple deadlines to complete essential tasks.
The employee generally works in a fast-paced and frequently stressful environment, must attend work on a regular and reliable basis, and adhere to all workplace policies, and may be called upon to work outside regular business hours.
Teaches and trains others regularly. Occasionally travels regularly from the office to various work sites or from site-to-site. Frequently requires physical work site.
ADDITIONAL INFORMATION
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies. As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures, as well as all data security guidelines established within the companys Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employees responsibility to comply with the companys Code of Business Conduct, which includes but is not limited to adherence to applicable federal and state laws, rules, and regulations, as well as company policies and training requirements.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org.
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Apply Job Details Job category: Provider Services Position Type: Full Time Posted: 2025-12-16T16:40:02.5659240000 Locations: Pittsburgh, PA 15222 PAP Penn Avenue Place Line of Business: Entity Recruiter: Hiring Manager Experience Level: Req ID J273080 Share Facebook Twitter LinkedIn Whatsapp Email Copy URL Apply Open in new tab icon Arrow left icon Twitter icon Facebook icon LinkedIn icon Instagram icon Youtube icon Glassdoor icon Featured Links Competitively Sensitive Information Cyber Security Notice at Collection E-Verify English E-Verify - Employee Rights and Responsibilities Data Protection Sitemap Terms of Service Do Not Sell Share E-Verify Spanish Digital Privacy Policy Highmark Health is an independent licensee of the Blue Cross Blue Shield Association.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org.
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Highmark provides millions of people with the security of quality health insurance
Our history of helping families and companies with their health insurance needs dates to the 1930s, when our predecessor companies were established to help Pennsylvania's residents pay for health care.
Highmark was created in 1996 by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield (now Highmark Blue Shield) and Blue Cross of Western Pennsylvania (now Highmark Blue Cross Blue Shield). We are now one of the largest health insurers in the United States.
Highmark's officers and board of directors set the company's strategic direction and corporate policies. They are guided by our mission, vision and values.