Senior Provider Engagement Network Specialist - Hybrid

Emblem Health is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, Emblem Health partners with top hospitals and doctors, including its own Advantage Care Physicians, to deliver quality, affordable, convenient care.

At over a dozen Emblem Health Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information,  .

Build, optimize and enhance networks through relationship development with key Providers, acting as a vital link between partners and Emblem Health. 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 Emblem Health departments, including grievances, disputes, and provider/member billing complaints. Represent and advance Emblem Health’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,…