Healthfirst

The Director, Out-of-Network Contracting will report directly to the VP of Provider Network Strategy and Optimization and will serve as the Company’s central authority for establishing, negotiating, and maintaining Out-of-Network contractual arrangements, with a primary focus on reducing OON spend through disciplined contracting strategies and network expansion opportunities. This role has end-to-end accountability for the development, negotiation, execution, and governance of all OON contractual arrangements, with a mandate to materially reduce OON spend, improve unit cost performance, and expand sustainable network access. The Director will be responsible for developing contracting solutions to address escalated OON unit cost issues and formalizing rate agreements across facility, professional, ancillary, and behavioral health providers. The function will consolidate all OON contracting activities under a single, centralized organization to drive consistency, compliance, and cost efficiency. This role will own the development and maintenance of OON contracting policies, procedures, and rate methodologies, informed by regulatory requirements, market intelligence, and network access needs. The Director will develop efficiencies that reduce reliance on episodic negotiations by converting repeat OON utilization into structured contractual arrangements, including opportunities to transition OON providers into Healthfirst’s contracted network at sustainable rates. The role will establish the long-term contracting vision, operating model, and rate strategy for OON providers, ensuring alignment with regulatory requirements, market dynamics, and Healthfirst’s affordability and access objectives.

This position requires three days per week in office (Tues/Wed/Thurs) at 100 Church St. New York, NY.

Responsibilities

• Set the enterprise strategy for Out-of-Network contracting, including rate methodologies, provider segmentation, and conversion strategies to bring high-utilization OON providers into the contracted network

• Own accountability for OON contracting financial outcomes, including unit cost reduction, medical cost savings, and mitigation of OON spend

• Design and govern the operating model for centralized OON contracting across facility, professional, ancillary, and behavioral health providers

• Establish and maintain enterprise policies, procedures, and rate guidelines that ensure consistency, compliance, and scalability and in alignment with regulatory requirements and market conditions

• Lead and develop a team responsible for negotiating and executing Out-of-Network contracts

• Represent Healthfirst in external-facing negotiations with providers and other stakeholders as required

• Partner with Finance and Medical Economics to develop savings targets, forecasts, and performance tracking tied to OON contracting activity

• Ensure compliance with Medicare, Medicaid, and Commercial regulatory requirements and proactively mitigate contracting and reimbursement risk

• Translate regulatory changes into contracting strategy

• Consolidate facility, professional, ancillary, and behavioral health OON contracting functions to drive standardization and medical cost savings

• Partner with Provider Data, Medical Economics, and DSE leadership to assess provider access gaps and recommend contracting or network participation strategies

• Identify and advance opportunities to transition high-utilization OON providers into contracted status at Healthfirst rates

• Oversee OON contracting needs to satisfy regulatory gaps in the network.

• Oversee new OON provider request to join the network.

• Establish and maintain strong working relationships with Regulatory, Legal, Finance, teams to ensure compliant and enforceable contracting outcomes

• Participate in cross-functional forums to assess the contracting impact of OON requests

• Lead the end-to-end OON contracting strategy to materially reduce organizational OON spend

• Maintain oversight of contract inventory, savings realization and documentation

• Develop and present executive-level materials related to OON contracting performance, inventory, savings, and strategic initiatives

• Lead and participate in high-stakes provider contract negotiations

• Provide daily staff supervision, coaching, mentoring, and performance oversight

• Conduct ad hoc analyses to identify root-cause drivers of OON utilization and contracting gaps

• Perform additional internal and external duties as assigned

• Serve as an advocate for Providers within Healthfirst while balancing affordability, access, and sustainability

Minimum Qualifications

• Bachelor’s Degree from an accredited institution

• 10+ years of progressive experience in Managed Care contracting, network management, or related payer functions

• Deep expertise in healthcare reimbursement methodologies, including Capitation, APR DRG, MS DRG, APGs, APCs, RBRVS, and Per Diems

• Demonstrated success leading enterprise-scale OON contracting strategies with significant financial impact

• Experience negotiating complex facility, professional, ancillary, and behavioral health contracts

• 7+ years of people leadership experience, including leading managers and senior professionals

• Strong knowledge of Medicare, Medicaid, and Commercial healthcare regulations and reimbursement structures

• Proven ability to influence executive stakeholders and lead cross-functional initiatives

Preferred Qualifications

• Master’s Degree (MBA, MHA, MPH, or related field)

• Experience owning or materially influencing budgets, forecasts, and savings targets

• Track record of leading large-scale transformation or cost optimization initiatives

• Familiarity with behavioral health contracting and reimbursement models

• Strong executive presence with the ability to represent the organization in high-stakes internal and external settings

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $154,600 - $236,555

• All Other Locations (within approved locations): $127,500 - $195,075

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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.