Senior Provider Contract Specialist - Hybrid
 EmblemHealth | |
 United States, New York, New York | |
 May 21, 2025 | |
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Summary of Job
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.
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 Additional Information
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