Sr. Healthcare Provider Contracting Analyst

Central Coast Salary Range: $120,970 - $181,455

Job Summary

The Senior Financial Analyst - Provider Contracts independently performs complex financial modeling, reimbursement rate development, and provider contract change analysis for Medicaid Managed Care & Medicare Advantage D-SNP Plan. This role utilizes advanced SQL, claims data analysis and financial modeling techniques to assess the financial impact of provider contracts including fee for service, capitation, and value based arrangements, while ensuring alignment with state regulatory requirements, quality initiatives, and organizational affordability objectives.

Serving as a subject matter expert in provider reimbursement and value based payment analytics, this position supports data driven contracting, negotiation, and provider performance strategies through close collaboration with Provider Contracting, Provider Relations, Quality, and IT/Data Analytics departments.

Key areas of responsibility include, but are not limited to:

• Provider Contract Financial Analysis

• Rate Development Modeling

• Advanced SQL & Data Analysis

• Cross-Functional Partnership & Strategic Support

• Data Governance, Accuracy & Regulatory Compliance

• Leadership, Mentorship & Operational Support

• Other duties as assigned

Duties and Responsibilities

1. Provider Contract Financial Analysis

• Perform detailed financial impact analysis for:

• New provider contracts

• Contract renewals, amendments, and rate adjustments

• Benefit changes, carve ins/outs, and escalators

• Value based contracting arrangements, including shared savings, shared risk, quality incentives, and performance based payments

• Analyze utilization, unit cost, PMPM, and total cost of care impacts using historical claims and encounter data.

• Support facility, professional, and ancillary provider reimbursement structures across the Medicaid and Medicare lines of business, including capitation, fee-for-service (FFS) and value based payment models or hybrid models.

2. Rate Development & Modeling

• Develop provider reimbursement models including:

• Fee for service (CPT/HCPCS, DRG, APC)

• Case rates, per diems, and bundled payments

• Capitation, value based payments, and alternative payment models (APMs)

• Build scenario based financial models-covering upside and downside risk-to support contracting negotiations and leadership decisions.

• Develop financial methodologies to support value based contract components such as incentive pools, withholds, risk corridors, benchmarks, and performance thresholds.

• Ensure contract financial assumptions align with:

• Medicaid state contract and value based purchasing requirements

• CMS Medicaid Managed Care Guidance

• Network adequacy, access, quality, and affordability standards

3. Advanced SQL & Data Analysis

• Use advanced SQL to:

• Extract, transform, and analyze large Medicaid claims datasets

• Develop custom datasets for contract modeling, reimbursement analysis, and value based performance measurement

• Validate utilization, unit cost, trend, and attribution assumptions used in financial and VBC models

• Analyze provider performance against cost, utilization, and quality metrics tied to value based arrangements, including calculation of earned incentives, shared savings, or losses.

• Create reproducible, well documented SQL queries to support ongoing contract evaluations and value based reconciliations.

• Partner with data analytics teams to ensure data integrity, consistency, and appropriate methodology for both reimbursement and VBC reporting.

4. Cross Functional Partnership & Strategic Support

• Partner closely with Provider Contracting to support negotiations with data backed financial insights across fee for service and value based agreements.

• Collaborate with Provider Network, Quality and Clinical teams to align financial models, benchmarks, and performance targets for value based contracts.

• Translate complex analytical findings into clear, actionable messages for non finance stakeholders, including summaries of value based performance, risks, and opportunities.

5. Data Governance, Accuracy & Regulatory Compliance

• Document assumptions, methodologies, benchmarks, and reconciliation logic supporting provider contract financial reviews and value based arrangements.

• Ensure analyses comply with:

• CMS & State Regulations

• State specific reimbursement and value based purchasing requirements

• Internal financial controls and audit standards

• Support internal and external audits, contract reconciliations, and regulatory reporting related to provider reimbursement and value based payments.

6. Leadership, Mentorship & Operational Support

• Serve as a subject matter expert in provider contract financial analysis, reimbursement modeling, and value based payment evaluation.

• Review and validate analyses produced by junior analysts, including value based performance calculations.

• Contribute to standardization, automation, and process improvement initiatives for contract modeling, VBC analytics, and performance reporting.

7. Other duties as assigned

Knowledge/Skills/Abilities

• Strong analytical and quantitative problem solving skills

• Advanced SQL querying and data analysis skills, including the ability to extract, manipulate, validate, and analyze large healthcare datasets.

• Strong proficiency in Microsoft Excel, including pivot tables, advanced formulas, and modeling techniques.

• Financial evaluation of value based care and alternative payment models

• Clear written and verbal communication skills with the ability to present complex financial information to technical and non-technical audiences

• Sound financial judgment, risk assessment, and attention to detail

• Skilled in Collaboration and relationship management across cross-functional departments including finance, contracting, quality, and clinical teams

• Knowledge of healthcare finance, provider reimbursement methodologies, and managed care operations, including Medicaid and Medicare Advantage/D-SNP programs.

• Knowledge of provider contracting structures, including fee-for-service, capitation, shared savings, and value-based payment arrangements.

• Knowledge of healthcare claims processing, encounter data, and financial reporting principles.

• Advanced analytical and financial modeling skills, with the ability to interpret complex datasets and identify financial trends and impacts.

• Ability to independently perform complex financial analysis with a high degree of accuracy and attention to detail.

• Ability to translate large volumes of financial data into actionable business insights and strategic recommendations.

• Ability to maintain confidentiality and exercise sound financial judgement in handling sensitive financial and provider information.

• Ability to work effectively in a fast-paced, collaborative environment while meeting deadlines.

• Strong understanding of healthcare claims data, reimbursement methodologies, value based payment models, and unit cost analysis.

• Advanced Excel skills (financial modeling, complex formulas, scenario analysis).

• Ability to independently manage multiple complex contract analyses in a deadline driven environment.

Education and Experience

• Bachelor's degree in Finance, Accounting, Economics, Healthcare Administration, or related field.

• Minimum of five (5) years of progressively responsible healthcare financial analysis experience, preferably within healthcare, managed care, provider contracting, or health plan operations.

• Minimum of three (3) years of experience performing healthcare reimbursement analysis, provider payment modeling, or contract financial analysis.

• Experience supporting a Medicaid Managed Care Plan or Medicaid line of business.

• Advanced experience using SQL, including: complex joins, subqueries, aggregations, and performance conscious query design.