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Provider Contract Specialist Jobs

Company

EmblemHealth
Address New York, NY, United States
Employment type CONTRACTOR
Salary
Category Insurance
Expires 2023-07-04
Posted at 10 months ago
Job Description
Summary Of Position


  • Responsible for day to day operations for all activities related to contracts with minimal supervision and direction, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as communication of Plan policies and procedures.
  • Act as a liaison and operate as a vital link between specific Facility, Ancillary, Delegated and/or Professional providers and EmblemHealth.
  • Contact for all escalated issues from the Provider and internal EmblemHealth departments, including grievances, disputes, and provider/member billing complaints.


Responsibilities


  • Ensure and coordinate notification and education of various departments within the EH on contract terms and related issues and conditions.
  • Ensure the accuracy of provider demographic data in the Plan’s database: review provider data for assigned Providers; handle provider requests for demographic changes; research provider address discrepancies identified by provider returned mail and potential provider demographic errors identified by other Plan departments or initiatives.
  • Coordinate delegated credentialing functions and activities.
  • May recruit available providers to fulfill Network deficiencies.
  • Provide timely, useful, and accurate responses to provider requests (provider requests for Plan materials; provider questions regarding fees, the Plan’s website and IVR; information in the Plan’s Provider Manual, and escalated claim inquiries.
  • 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.
  • Document all outreach activities in compliance with department standards.
  • Assist participating providers when issues require coordination of various Plan departments (Claims, Care Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, Credentialing, etc.).
  • Communicate with providers and respond to provider inquiries in a timely, accurate, and professional manner with minimal direction from leadership.
  • Perform additional duties as directed, assigned, or required.
  • Support the timely completion/coordination of claim inquiries and complaints for the Hospital, Ancillary, and/or Professional network; coordinate Joint Operating Committees (JOCs), claim review and resolution and support of audits when needed.
  • Assist providers in all matters related to contract disputes and ensure accurate contract and rate load implementations are done in a timely manner.


Education, Training, Licenses, Certifications


  • Bachelors’ degree in Health Care-related field, Public Administration, or Management.


Relevant Work Experience, Knowledge, Skills, And Abilities


  • Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and that problems are accurately represented for resolution. (R)
  • Ability to work well with various Plan departments is instrumental in the effectiveness of the position. (R)
  • Knowledge of provider and payor roles, responsibilities and challenges. (R)
  • 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. (R)
  • Strong customer service skills and the ability to maintain an excellent rapport with providers and their staff. (R)
  • 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. (R)
  • PC skills including proficiency in Microsoft Office Suite. (R)
  • 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. (R)
  • Ability to work independently assignments and maximize opportunities to support. (R)
  • An understanding of health care financing, access issues, delivery systems, quality controls, and legislation. (R)
  • Proficiency testing in Excel, Word and other Microsoft applications. (R)
  • 3 – 5+ years of direct provider relations experience. (R)


Additional Information


  • Requisition ID: 1000000767
  • Hiring Range: $52,000-$92,000