Sr. Provider Contracting Manager
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY
The Sr. Provider Contracting Manager is a senior-level, non-supervisory individual contributor responsible for provider network development, strategic provider contracting, and complex contract negotiations across Community Health Choice's provider network.
The role identifies opportunities to expand value-based care agreements and alternative payment arrangements for existing and new lines of business, solves complex contracting challenges focused on improving cost and quality performance, negotiates provider agreements, coordinates quality performance and data submission requirements, ensures regulatory compliance, and maintains effective provider relationships.
The Sr. Provider Contracting Manager serves as a subject matter expert for provider contracting strategies and collaborates with Provider Engagement, Compliance, Legal, Quality, Finance, Credentialing, Claims, and Network Operations to implement provider agreements, support operational excellence, and achieve departmental and organizational objectives.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Negotiate Provider and Value-Based Care Contracts:
Negotiate complex contract language and rates with hospital, physician, ancillary, and LTSS providers in accordance with established parameters and guidelines
Collaborate with Compliance, Legal, Quality, Finance, and Credentialing to finalize provider contracts, amendments, and new agreements
Ensure compliance with regulatory and product requirements related to provider contracting, including network adequacy standards
Provide senior-level negotiation support and recommendations for complex, high-impact, or escalated provider agreements
Expand Provider Networks and Value-Based Provider Arrangements:
Lead quality performance monitoring, data submission coordination, and data integrity activities related to clinical quality measures
Identify opportunities to expand provider networks and value-based provider agreements for existing and new lines of business
Conduct external meetings with prospective and existing providers to negotiate or renegotiate agreements
Collaborate with internal teams to assess contracting opportunities and facilitate network expansion efforts
Compliance, Network Adequacy, and Contract Governance:
Ensure compliance with regulatory requirements and product specifications related to provider contracting functions
Monitor network adequacy and coordinate adjustments needed to meet regulatory standards
Coordinate with Network Management, Claims, Payment Solutions, Provider Data Integrity, Quality, and other stakeholders to support accurate contract reimbursement, quality reporting, and adherence to requirements
Identify contract risks, inconsistencies, and implementation concerns and recommend appropriate resolution
Complex Contract Implementation and Issue Resolution:
Lead cross-functional implementation activities for complex provider contracts, amendments, alternative payment arrangements, and new agreements
Analyze and resolve escalated contracting, reimbursement, implementation, and operational issues in partnership with internal stakeholders and providers
Communicate contract terms, implementation requirements, and operational impacts clearly to affected stakeholders
Support consistent interpretation and administration of executed provider agreements
Provider Relationship Management:
Serve as a senior liaison between Community Health Choice and its providers, facilitating communication and addressing complex or escalated issues
Maintain productive provider relationships to support contracting, implementation, quality performance, and data submission activities
Represent Network Management in provider meetings and cross-functional discussions requiring advanced contracting expertise
Departmental Goals, Process Improvement, and Knowledge Support:
Contribute to departmental goals outlined in the annual business plan
Participate in and support process improvement initiatives that enhance contracting quality, consistency, efficiency, and effectiveness
Provide technical guidance, contract knowledge, and informal support to Provider Contracting team members without direct supervisory responsibility
Perform other duties as assigned to support the department and organization
QUALIFICATIONS:
Education/Specialized Training/Licensure: High school diploma or equivalent required.
Bachelor's degree in business, Healthcare Administration, Finance, or a related field preferred.
Work Experience (Years and Area): Six (6) years of progressively responsible provider contracting and contract negotiation experience in healthcare or managed care, including experience with complex provider agreements
Experience with hospital, physician, ancillary, LTSS, delegated provider arrangements, and alternative payment or value-based agreements
Management Experience (Years and Area): N/A - This is a non-supervisory senior individual contributor role
Experience leading complex negotiations, mentoring peers, or coordinating cross-functional contract implementation activities without direct people management responsibility
Software Proficiencies: Microsoft Office, including Word, Excel, and Outlook
Experience with QNXT, Salesforce, contract management, provider data, claims, quality reporting, or data submission systems
Other: Travel is required approximately 50% of the time. Access to a vehicle and a valid Texas driver's license are required. Advanced managed care contract negotiation experience is required
Experience within the Houston market and with STAR+PLUS, LTSS, HCBS, Medicare, alternative payment arrangements, clinical quality measures, or value-based contracting preferred.