[Remote] Sr. Healthcare Provider Contracting Analyst

Note: The job is a remote job and is open to candidates in USA. CenCal Health is seeking a Senior Healthcare Provider Contracting Analyst to perform complex financial modeling and reimbursement rate development for Medicaid Managed Care & Medicare Advantage D-SNP Plan. This role involves analyzing provider contracts and collaborating with various departments to support data-driven contracting and negotiation strategies.

Responsibilities

• 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
• 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
• 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
• 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
• 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
• 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
• Other duties as assigned

Skills

• 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
• 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

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