[Remote] Health Plan Network Strategy Consultant
Note: The job is a remote job and is open to candidates in USA. Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system dedicated to improving community health across New Mexico. The Health Plan Network Strategy Consultant will lead strategic initiatives in provider contracting and network development, ensuring compliance with regulations while enhancing access and availability standards.
Responsibilities
- Leading the development and negotiation of high-value provider contracts—exceeding $1B annually—with major hospital systems and provider organizations.
- Owning complex contract modeling and network adequacy technologies, ensuring alignment with strategic goals.
- Overseeing provider contract performance audits and remediation strategies in collaboration with actuarial, finance, medical economics, claims operations, and payment integrity teams.
- Monitoring network adequacy and ensuring compliance with federal and state regulations, while identifying and addressing access gaps.
- Conducting ongoing analysis of provider networks from cost, coverage, and growth perspectives to inform strategic expansion decisions.
- Leading provider contract due diligence for network development in expansion markets.
- Serving as a subject matter expert on reimbursement methodologies and educating key operational teams.
- Supporting budgeting and forecasting efforts related to medical trend and unit cost increases.
- Driving contract performance by aligning negotiated rates with budgeted medical cost trends.
- Analyzing claims data and market dynamics to guide strategic contract negotiations.
- Building and maintaining executive-level relationships with provider organizations.
- Collaborating with Presbyterian System leaders to grow accretive market share and enhance the value of the health plan through innovative cost-of-care strategies.
- Staying abreast of industry trends, regulatory changes, and emerging care delivery models to continuously refine network strategy.
Skills
- Bachelors degree or equivalent experience in Business Administration, Healthcare Administration or related field.
- 10 years of combined experience in managed care, provider contracting, provider network operations and management, and health plan operations experience.
- Knowledgeable of the full continuum of reimbursement methodologies to include fee-for-service, risk sharing, and capitation.
- Must possess strong communication skills and be comfortable with public speaking.
- Excellent financial and analytics as well as business acumen and familiarity with the operations of sophisticated large integrated delivery systems, innovative business models, managing of a complex multi-institutional and multi-market environment, joint ventures, and evolving population health and payment models.
- Knowledge of current national health care policies and trends, as well as leadership, management, and quality improvement concepts.
- Master’s degree preferred.
- Minimum of 10 years of combined experience in managed care, provider contracting, network operations, and health plan management.
Benefits
- Medical
- Dental
- Vision
- Disability coverage
- Life insurance
- Optional voluntary benefits
- The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities - like challenges, webinars, and screenings - with opportunities to earn gift to earn gift cards and other incentives.
Company Overview
- Presbyterian Healthcare Services exists to improve the health of patients, members and the communities they serve. It was founded in 1908, and is headquartered in Clovis, New Mexico, USA, with a workforce of 10001+ employees. Its website is http://www.phs.org.
Company H1B Sponsorship
- Presbyterian Healthcare Services has a track record of offering H1B sponsorships, with 79 in 2025, 86 in 2024, 85 in 2023, 93 in 2022, 86 in 2021, 76 in 2020. Please note that this does not guarantee sponsorship for this specific role.
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