Vanessa M. McDonald
Newton,USA
Summary
Senior healthcare professional with extensive expertise in contract negotiation and provider relationship management. Recruiting and building network across multiple states. Achieved significant reductions in out-of-network expenditures while establishing effective provider networks across multiple states. Strong knowledge of insurance policies and compliance requirements, coupled with a proven track record in managing complex contracts and fostering robust client relationships.
Overview
32
32
years of professional experience
1
1
Certification
Work History
Senior Contract Manager, Network Contracting
Optum California (UHG)
03.2025 - Current
- Successfully manage and develop the Optum California network of healthcare providers including primary care and specialty doctors across Orange County California and neighboring counties.
- Negotiate and recruit for all lines of business i.e., Commercial, Medi-Cal and Senior.
- Achieve unit cost performance and medical cost trend management targets through effective contract negotiations.
- Evaluate and lead contract negotiations utilizing financial modeling to ensure compliance with company reimbursement standards.
- Established and maintained strong business relationships with clients to optimize network composition and quality of care.
- Recruit out-of-network providers with high utilization and built networks where gaps existed.
- Negotiate value-based contracts to improve quality and patient outcomes through innovative incentive structures.
- Participate in recruitment of Ancillary providers and collaborate with analytics team to conduct financial analysis and identify competitive reimbursement strategies.
- Fill network gaps and negotiate letter of agreements for all specialty type providers that include physicians, Ancillary and facility for out-of-network services.
- Ensured timely implementation of new or renewed contracts by reviewing contract language, managing redlines, and drafting version while adhering to company policies and legal requirements to minimize risk.
- Function as a resource and subject matter expert.
- Manage, identify and direct complex contractual issues as well as system demographic updates.
- SME for junior contractors and in other state territories, and provide support to various departments.
Sr. Manager, Behavioral Health Network Management
Aetna/CVS Health
08.2021 - 03.2025
- Spearhead contract negotiations with high-volume behavioral health providers, hospital systems, and facilities to optimize network coverage and cost efficiency for various states.
- Build relationships with internal and external key clients
- Develop and implement value-based contract relationships aligned with strategic business objectives.
- Lead complex dispute resolution and settlement negotiations with large market-based healthcare groups.
- Design and execute provider recruitment strategies to meet network expansion targets and adequacy requirements.
- Partner with compliance and legal to review contract language, manage redlines, and ensure adherence to legal requirements.
- Oversee contract performance analysis and reimbursement modeling to drive strategic decision-making.
- Collaborate cross-functionally to manage provider compensation, pricing development, and tactical cost management initiatives.
- Reduce NJ out-of-network spend by 8% through strategic provider recruitment, generating over $1m in annual savings.
- Secured five company recognition within 18 months for exceptional performance.
- Successfully closed network adequacy gaps in New Hampshire and New Jersey market for two consecutive years.
- Work together with Aetna’s claims team to solve complex claim issues.
- Established as a SME for Junior contractors.
- Work cross functionally with credentialing by streamlining the provider credentialing process by collecting, tracking, pre-review and follow up of applications, reducing average turnaround time by 50%.
- Systems (EPDB, Salesforce, PRMS, SCM, QuickBase, HRP ….)
Network Contract Manager
Optum Behavioral Healthcare (UHG)
08.2017 - 08.2021
- Successfully managed and developed the Optum Behavioral Health Hospital and Free-standing facility Network across multiple states and lines of business, including Commercial, Medicaid and Medicare.
- Achieved unit cost performance and medical cost trend management targets through effective contract negotiations.
- Evaluated and led contract negotiations utilizing financial modeling to ensure compliance with company reimbursement standards.
- Established and maintained strong business relationships with clients to optimize network composition and quality of care.
- Recruited out-of-network providers with high utilization and built networks where gaps existed.
- Negotiated value-based contracts to improve quality and patient outcomes through innovative incentive structures.
- Participated in recruitment of veteran’s affairs community network and collaborated with analytics team to conduct financial analysis and identify competitive reimbursement strategies.
- Filled network gaps in key markets through targeted provider recruitment and contracting.
- New Jersey.
- Negotiated single-case agreements for out-of-network mental health and substance abuse facilities, as well as large health systems.
- Ensured timely implementation of new or renewed contracts by reviewing contract language, managing redlines, and drafting version while adhering to company policies and legal requirements to minimize risk.
- Function as a resource and subject matter expert for others with less experience.
- Managed, identified, and directed complex contractual issues as well as system demographic updates.
- Assisted other state territories and provide support to Provider relations representatives as needed.
Ancillary/Physician/Hospital -Network Contract Manager
UnitedHealth Group
02.2015 - 08.2017
- Managed and developed the Hospital, Physician and Ancillary Networks, yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance, trend management, and produces an affordable as well as predictable product for customers and business partners.
- Evaluated and led contract negotiations in compliance with company contract templates and reimbursement structure standards.
- Review financial and actuary models to build analysis and assist in negotiations.
- Negotiated Value based contracts to improve quality and patient outcomes through incentives.
- Reviewed and managed redlines, draft versions while ensuring compliance with company policies and legal requirements to minimize risk.
- Responsibilities also include establishing and maintaining strong business relationships ensuring the network composition includes an appropriate distribution of specialties.
- Evaluated and recruited out-of-network providers with high utilization to build network whereas needed.
- Negotiated single case agreements for Out of Network Hospitals, Home Health, LTAC, SNF, Infusion therapy and Ancillary providers.
- Timely implementation of new and renewed contracts.
- Subject matter expert for junior contractors with less experience.
- Managed, identified, and directed complex contractual issues as well as system demographic updates.
Ancillary Services Contractor
Healthfirst Inc.
Manhattan, USA
07.2012 - 02.2015
- Company Overview: Manhattan, New York
- Managed and recruited a network of ancillary providers for all lines of Health first’s business in New York and New Jersey (Medicaid, Medicare, CHP and MLTC).
- Negotiate contracts with Physicians and Ancillary Providers.
- Maintained network in accordance with NYS requirements and network need.
- Monitor and audit system load activities to ensure accurate information, including demographic, payment, and fee schedule information.
- Single point of contact for all contractual complaints.
- Facilitate provider education training to increase their familiarity and satisfaction with Healthfirst systems and strategies.
- Create trend analyses and summaries for decision-making purposes.
- Interface with market leaders to align contracting needs, initiatives, and business efforts.
- Set targets and priorities to meet market network needs.
- Work closely with Medical Management to negotiate out of network authorizations, assist with member issues, complaints, and balance billing problems.
- Represent Ancillary Services at meetings.
- Work closely with the finance department to provide information to assist in developing reports to review cost trends.
- Oversee and develop Ancillary provider recruitment and strategy, as necessary, for regulatory, clinical or customer satisfaction purposes for Healthfirst to expand its books of business.
- Accounts include Radiology, DME, Mobile Radiology, Dialysis, Infusion, SNF, and LTAC, Adult day care, Behavioral Health, and Physical/Occupational/Speech Therapy.
- Negotiate Single Case agreements for Hospital, Lab (pharmacy), Ancillary and Physician services.
- Collect all credentialing documentation related to provider participation related to credentialing necessary to comply with Plan standards.
- Conduct credentialing site visits.
- Manhattan, New York
Senior Ancillary Contract Manager
Emblem Health
Manhattan, USA
01.2010 - 07.2012
- Company Overview: Manhattan, NY
- Establish and maintain a network of free-standing Radiology/Cardiology centers, Hospital based physicians and large IPA groups to support both commercial and state sponsored Programs.
- Support the implementation and ongoing maintenance of IPA group contracts.
- Work closely with Care Core National team.
- Evaluate and lead contract negotiations; maintain network in accordance with NYS requirements and network need; Timely implementation of negotiated rates for new or renewed contracts and oversee to assure the end-to-end process.
- Collaborates with other departments to facilitate timely resolution and root cause of issues, grievances, and claim disputes.
- Educate providers on new products, enhancements, Plan(s) initiatives, policies and procedures, related questions or issues for all Emblem Health plans including Medicare/Medicaid.
- Conduct field and site visits monthly.
- Participate in the development and implementation of corporate wide goals to assure quality outcomes.
- Ensure the accuracy of the providers’ demographic data.
- Collect credentialing documents according to the plans policies and procedures.
- Conduct site visits.
- Create, manage contracts and materials related to credentialing necessary to comply with Plan standards of EH Center Networks; Supervise Jr. Contracting Specialist.
- Manhattan, NY
Provider Relations Consultant
Humana Inc.
Jersey City, USA
12.2008 - 11.2009
- Company Overview: Jersey City, NJ
- Humana’s Liaison for the NJ provider community and Veterans.
- Educate all provider type specialties for the New Jersey geographic area on Humana’s Medicare Advantage and Veterans program.
- Responsible for providing value added remote communications and services to Humana's provider partners; On an ongoing basis managed and directed the entire provider relations process by educating and supporting providers regarding Humana’s Medicare Advantage plan operations and issues through telephonic contact , face to face meetings and group seminars.
- Recruit physicians in needed geographic area.
- Responsible for provider file updates.
- Provide education/training to Humana’s provider partners by working with medical affairs to resolve member service issues; work with the claims processor to resolve claims issues; developed provider relations plans; communicated reimbursement logic to providers.
- Maintained relationships with providers to ensure accomplishment of departmental and corporate goals.
- Jersey City, NJ
Provider Relations Field Representative
Horizon Blue Cross Blue Shield of NJ
Newark, USA
11.1998 - 12.2008
- Company Overview: Newark, NJ
- Educated, monitored, analyzed documents and interacted with all specialty type providers face to face daily to ensure provider cooperation, understanding and effective participation in Horizon BCBSNJ products.
- Scheduled site visits to ensure office is following NCQA guidelines, assist in the negotiation and renegotiations of contracts as well as support the contracting department by meeting with provider groups to discuss their incentive awarded through participation in Horizons Clinical quality health care initiative.
- Established strong, solid relationships with physicians/administrators at key provider offices within assigned territory.
- Responsible for all provider file updates.
- Ensured compliance with Federal and State guidelines pertaining to network adequacy.
- Managed provider education, facilitation and resolution of complex, urgent problems.
- Participate in the planning, organizing and presentation of seminars, conventions, speeches, etc. to various provider, billing service, medical society and internal groups.
- Maintain a thorough knowledge of healthcare industry trends and developments through the review of industry publications, newsletters, and formal training.
- Effectively troubleshoot complex claim situations, program/policy disputes, executive, VIP inquiries.
- Train new field representative.
- Promote Medication dispenser machines to doctor offices.
- Promote Via Cord and Sneakers programs.
- Work closely with LabCorp.
- Newark, NJ
Member /Provider Service Liaison and Quality analyst
Prudential Healthcare
Cranbury, USA
07.1993 - 11.1998
- Company Overview: Cranbury, NJ
- Received, evaluated, managed all member and provider inquiries as well as educate on products and services.
- Resolve claim issues and service problems.
- Maintain the system for tracking purposes, referral information and troubleshooting.
- Manage high daily volumes and workflows.
- Assisted and coached other team members.
- Met weekly and monthly with various teams to coach, educate and provide monthly quality scores to increase their customer service skills.
- Maintain strong relationships with customers and internal partners to deliver superior customer experience.
- Support the Pharmacy department with overrides, refills and authorizations and work with third party administrators.
- Educate members on prescription refills, order status and insurance coverage.
- Cranbury, NJ
Education
Psychology - Sociology
Southern New Hampshire University
Online12.2026
High School -
West Orange High School
West Orange, NJSkills
- Active listening
- Rapport building
- Conflict resolution
- Problem solving
- Financial modeling
- Contract negotiation
- Network development
Certification
- Certificate of Mentorship
- Microsoft office certification in Excel, Word, PowerPoint, and Access
Timeline
Senior Contract Manager, Network Contracting
Optum California (UHG)
03.2025 - Current
Sr. Manager, Behavioral Health Network Management
Aetna/CVS Health
08.2021 - 03.2025
Network Contract Manager
Optum Behavioral Healthcare (UHG)
08.2017 - 08.2021
Ancillary/Physician/Hospital -Network Contract Manager
UnitedHealth Group
02.2015 - 08.2017
Ancillary Services Contractor
Healthfirst Inc.
07.2012 - 02.2015
Senior Ancillary Contract Manager
Emblem Health
01.2010 - 07.2012
Provider Relations Consultant
Humana Inc.
12.2008 - 11.2009
Provider Relations Field Representative
Horizon Blue Cross Blue Shield of NJ
11.1998 - 12.2008
Member /Provider Service Liaison and Quality analyst
Prudential Healthcare
07.1993 - 11.1998
Psychology - Sociology
Southern New Hampshire University
High School -
West Orange High School