"Director of Provider Contracting and Reimbursement"

Job Description

Principal Responsibilities

1. Develop, maintain, and optimize a comprehensive healthcare provider network to support the Yale University community, including proactive gap analysis and corrective action planning.
2. Build and manage relationships with external providers and internal stakeholders to support network design, configuration, and preferred site-of-care strategies.
3. Negotiate, renegotiate, and maintain contracts across all provider types, ensuring accurate documentation of terms, rates, and compliance with organizational standards.
4. Partner with legal, compliance, finance, and medical economics teams to structure, review, and remediate contracts and processes that protect Yale Health’s interests.
5. Oversee claims operations, including processing, auditing, training, quality assurance, and development of best practices that drive accuracy, efficiency, and continuous improvement.
6. Monitor and analyze claims and network performance data; develop dashboards, KPIs, and reporting to inform leadership decisions and operational strategy.
7. Ensure compliance with applicable laws, regulations, accreditation standards, and internal controls for claims, contracts, and provider network operations.
8. Lead initiatives to enhance infrastructure, automation, and scalability across network and claims functions.
9. Manage provider directory accuracy and related communication efforts, ensuring completeness and integrity of publicly accessible information.
10. Collaborate with university leaders, Yale Health chiefs and managers, and external partners to represent organizational needs, share best practices, and drive cross-functional alignment.
11. Support value-based care program design and provider reimbursement policy development, contributing to cost-of-care forecasting, financial planning, and premium alignment.
12. Effectively represents the organization's needs, challenges, and opportunities at the University level. Proactively shares knowledge and best practices with others.
13. Perform additional duties as assigned by the Head of Finance and Business Strategy.

Required Education and Experience

Bachelor’s degree in a related field and 15 years of relevant experience or an equivalent combination of education and experience.

Overview

In 1971, Yale University established Yale Health to provide health services to its facility, staff and students through a multidisciplinary health maintenance organization located on campus. Yale Health has approximately 49,000 members including students, staff, faculty and their families who come from every state in the country and almost every country in the world and is committed to an inclusive workplace. We are celebrating over 50 years of service to the Yale community.

Our state-of-the-art facility at 55 Lock Street, is where our members receive most of their care from our 150+ providers. It is a 144,000 square foot medical facility with over 90 exam rooms, an Acute Care Department, a 15-bed inpatient facility with two negative pressure rooms, a diagnostic imaging suite including MR and CT scan, x-ray and ultrasound and a full-service retail pharmacy.

Reporting to the Head of Finance and Business Strategy, this role leads business strategy for Yale Health, a $500 million Yale University unit serving the University community. The position partners with senior leadership to shape strategies that meet Yale’s current and future healthcare needs.

Key responsibilities include overseeing provider network configuration and development, managing external provider reimbursement, and maintaining a comprehensive understanding of competitive healthcare reimbursement methodologies. The ideal candidate has 15+ years of experience recruiting and managing provider networks and negotiating, reviewing, and amending contracts with hospitals, physicians, physician groups, and ancillary providers across multiple payment models.

This role also serves as a core member of the claims leadership team, responsible for designing and leading claims processes, managing claims data and reporting, ensuring quality and compliance, and driving continuous process improvement. Strong knowledge of industry-standard reimbursement practices is essential.

The successful candidate will demonstrate strategic leadership, performance management capabilities, and skill in coaching and mentoring. They will bring strong business acumen, communicate effectively with diverse audiences, and exhibit innovation, independence, and confidence. Effectively represents organization needs, challenges, and opportunities at the University level. Proactively shares knowledge and best practices with others. This leader must be a "big picture" thinker who provides effective guidance today while articulating forward-looking, innovative strategies, operating with energy and rigor across all areas of responsibility.

Schedule

Full Time - 37.5 HRS; Weekdays, Monday - Friday, 8:30 - 5:00; Occasional evenings, weekends, holidays or recess may also be required. Hybrid Position.

Required Skills and Abilities

1. Advanced knowledge of and experience with provider network development and contracting, including provider reimbursement methodologies, rules and industry norms. Healthcare network or market development experience. Broad industry knowledge to allow market assessment.
2. Practical experience in working with healthcare claims and business rules. Operational knowledge related to providers claim reimbursement. Ability to make quick, independent decisions based on strong business aptitude.
3. Knowledge of healthcare provider or health plan accounting/finance. Advanced knowledge of fiscal and regulatory compliance issues.
4. Well-developed analytical, organizational, and research skills including use of data analytic tools. Ability to analyze financial reports and identify trends and variances.
5. Well-developed managerial, decision-making, planning, organizational, problem resolution and leadership skills. Excellent written and oral communication skills including presentation skills. Mutually beneficial negotiation skills, including attention to detail.
6. Strong ability to lead, train and motivate staff, organize effective task forces, and project teams. Proven ability to lead change, innovate processes, and drive results. Passion for leading in a challenging and changing environment utilizing innovation, technology, and best practices.

Preferred Skills and Abilities

Three years of experience within a group practice and/or health plan.