Summary of JobBuild, optimize and enhance networks through relationship development with key Providers, acting as a vital link between partners and EmblemHealth. Develop provider contracting efforts, including but not limited to process oversight, strategic diligence & data, outreach, and contract negotiations. Responsible for day-to-day operations for all activities related to contracts, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as communication of Plan policies and procedures. Contact for all escalated issues from the Provider and internal EmblemHealth departments, including grievances, disputes, and provider/member billing complaints. Represent and advance EmblemHealth's interests in the provider market to improve quality, health outcomes, access, and experience while managing financial performance. "Provider" can include managing entity for health systems, facilities such as a specialty office, large faculty and group practices, delegated relationships, ancillary or ambulatory centers, value-based relationships, and the like.
Responsibilities- Recommend innovative contracting strategies to maximize cost containment, access, value, and quality through provider arrangements.
- Negotiate and communicate contract terms, payment structures, and reimbursement rates to providers in alignment with departmental tools; present outliers to leadership as needed.
- Ensure accurate contract and rate load implementations are done in a timely manner; complete wire forms and track payments as necessary.
- Remain current on provider reimbursement methodologies and identify provider reimbursement trends to assist in the development of provider contracting strategies.
- May recruit available providers to fulfill Network deficiencies.
- Accountable for understanding market trends, competitive information, and governmental models to inform decision-making.
- Responsible for ongoing network performance, contract renewals, and terminations, including aggregate and product-level performance analytics and management.
- Analyze financial impact of contract terms through usage of internal tools and collaboration with Healthcare Economics and Contract Configuration; understand and vet complex data in advance of secure distribution to provider organizations and executive leadership teams.
- Utilize clinical, financial, and quality data to identify and communicate areas of opportunity to the provider entities; collaboratively develop action plans to include targeted goals and interventions to impact these opportunities by coordinating health plan and provider entity resources.
- Perform contract reconciliations in collaboration with Finance, Capitation, and Quality, and ensure accurate reporting for internal financial reserves, Purchase Orders, and annual plans.
- Ensure the accuracy of provider demographic data in the Plan's database. This includes but is not limited to reviewing provider data for assigned Providers, handling provider requests for demographic changes, researching provider address discrepancies identified by provider returned mail and potential provider demographic errors identified by other Plan departments or initiatives.
- Communicate independently with providers and respond to provider inquiries in a timely, accurate, and professional manner; educate and direct provider to self-service tools.
- Serve as subject matter expert to assist internal and external contacts in all matters related to the contract, including payment policy, performance, attribution, and data accuracy. Track all contract terms via contract summaries.
- Lead resolution of complex issues requiring coordination of various Plan departments. These departments include but are not limited to Claims, Care Management, EDI, Quality, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, Compliance, Operations, Product, Sales, and Credentialing. Optimize interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.
- Ensure and coordinate notification and education of various departments within EmblemHealth on contract terms and related issues and conditions.
- Lead and facilitate provider meetings to drive resolution of policy, payment, contractual, or other items; including but not limited to Joint or Administrative Operating Committees. Coordinate and facilitate all internal and external meetings related to contract performance, consistent with contract stipulations.
- Assure regulatory and provider network compliance requirements are met for assigned providers.
- Coordinate delegated credentialing functions and activities.
- Perform outreach projects which may include requests by the Plan's State Sponsored Programs Department for DOH, IPRO and DOI notices, HEDIS medical record retrieval and other projects as needed. All outreach documented in compliance with department standards.
- Coach new and less experienced Specialists, as needed.
- Perform additional duties as assigned.
Qualifications- Bachelor's degree in Health Care-related field, Public Administration, or Management
- 4 - 6+ years of relevant, professional work experience (Required)
- 3+ years' experience in healthcare analytics, contracting or plan or provider operations, or related (Required)
- Additional experience/specialized training may be considered in lieu of educational requirements (Required)
- Demonstrated understanding of standard analytic methodologies and tools (Required)
- Excellent organizational, project management, and relationship management skills (Required)
- Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required)
- Proficiency with MS Office - Word, Excel, PowerPoint, Teams, Outlook, etc. (Required)
- Understanding of the clinical, economic, and quality components of healthcare (Required)
