Job Summary
Build, optimize and enhance our insurance networks through relationship development with key local network participants. Act as a liaison and operates as a vital link between specific Facility, Ancillary, Delegated and/or Professional providers and EmblemHealth. Develop provider contracting efforts, including but not limited to process oversight, strategic diligence, 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. '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 and the like.
Responsibilities
• Recommend innovative contracting strategies to maximize cost containment, access and quality through provider arrangements.
• Negotiate and communicate contract terms, payment structures, and reimbursement rates to providers.
• Remain current on provider reimbursement methodologies and identify provider reimbursement trends to assist in the development of provider contracting strategies.
• Assist providers in all matters related to contract disputes and ensure accurate contract and rate load implementations are done in a timely manner.
• Communicate independently with providers and respond to provider inquiries in a timely, accurate, and professional manner.
• Responsible for ongoing network participation and performance, including performance analytics and management, as well as contract renewals and terminations.
• Analyze financial impact of contracts and terms.
• Provide timely completion/coordination of claim inquiries and complaints for the Hospital, Ancillary, and/or Professional network. This includes the coordinating of Joint Operating Committees (JOCs), claim review and resolution and support of audits when needed.
• Responsible for the accuracy of all documentation in support of contracts.
• Serve participating providers when issues require coordination of various Plan departments. These departments include but are not limited to Claims, Care Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, and Credentialing.
• Provide timely, useful, and accurate responses to provider requests. This includes but is not limited to provider requests for Plan materials, and provider questions regarding fees, the Plan’s website and IVR, information in the Plan’s Provider Manual, and escalated claim inquiries.
• 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 the EH on contract terms and related issues and conditions.
• Coordinate delegated credentialing functions and activities.
• 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.
• May recruit available providers to fulfill Network deficiencies.
• 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.
• Perform additional duties as assigned.
Qualifications
• Bachelors’ degree in Health Care-related field, Public Administration, or Management
• 4 – 6+ years of direct provider relations experience (Required)
• Knowledge of provider and payor roles, responsibilities and challenges. An understanding of health care financing, access issues, delivery systems, quality controls, and legislation (Required)
• Strong customer service skills and the ability to maintain an excellent rapport with providers and their staff (Required))
• Ability to work well with various Plan departments is instrumental in the effectiveness of the position (Required)
• Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and that problems are accurately represented for resolution (Required)
• Time management skills and flexibility to work on multiple projects/assignments simultaneously, with ability to change focus in a crisis situation. Willingness to assume diverse duties and challenges (Required)
• Interpersonal skills to effectively maintain working relationships to get issues resolved or to obtain information through people, and to represent the Plan and the Department in a favorable light (Required)
• Ability to work independently assignments and maximize opportunities to support (Required)
• Analytical and problem-solving skills to identify needs in provider relationships, make recommendations as projects develop and follow through to resolution using available resources to achieve a solution (Required)
• Proficiency testing in Excel, Word and other Microsoft applications (Required)
• PC skills including proficiency in Microsoft Office Suite (Required)