Senior Provider Contract Specialist
Company: CONNECTI CARE, Inc
Location: New York
Posted on: November 22, 2021
Connecticare is a leading health plan in the state of
Connecticut and a subsidiary of EmblemHealth, a health and wellness
company that provides insurance plans, primary and specialty care,
and wellness solutions. WellSpark is a digital wellness company and
national subsidiary of EmblemHealth that offers a full suite of
products and solutions to reward people for healthy behaviors. To
protect the health and safety of our workforce, members, patients,
and the communities we serve, the EmblemHealth family of companies
require all new employees to be fully vaccinated for COVID-19.
Exemption/reasonable accommodations may be granted because of 1) a
qualifying medical condition or disability that makes getting the
vaccine unsafe for the individual, or 2) objection on the basis of
sincerely held religious beliefs and/or practices.
-- With direction from Director and in accordance with budget and
goals of Network Department, negotiates hospital contracts, and
maintains contractual relationships between the Plan and provider.
Manages, with direction of senior management, medical costs at
network and non-network hospitals. Responsibilities:
- Negotiates both financial and language terms of hospital
contracts utilizing internal end-to-end process.
- Manages providers in all matters related to contract disputes
and ensures accurate contract and rate load implementations.
Communicates independently with providers and responds to provider
inquiries in a timely, accurate, and professional manner.
- Manages claim inquiries and complaints for the Upstate Hospital
network. This includes the coordinating of Joint Operating
Committees (JOCs), claim review and resolution, and site visits to
address hospital's concerns.
- Work with detailed financial models, manipulate them
effectively and accurately to ensure appropriate decision making on
- Ensures and coordinates notification and education of various
departments within the EH on contract terms and related claims
issues and conditions.
- Assists in the recommendation of innovative contracting
strategies to maximize cost containment, access and quality through
provider arrangements; remains current on provider reimbursement
methodologies, and identifies provider reimbursement trends to
assist in the development of provider contracting strategies
- Works with Director/Vice President to develop strategy for
contracting on a go forward basis to manage unit cost and network
- Obtains documentation for credentialing and collects data
pertaining NY State Health Provider Network (HPN) reporting
- 4- 6 years experience in network management related role, such
as contracting or provider service. (R)
- Knowledge of provider contracting methodology and payor roles,
responsibilities and challenges. (R)
- Understanding of health care financing, access issues, delivery
systems, quality controls, and related healthcare
- Knowledge of provider contracting methodologies and payor
roles, responsibilities and challenges. An understanding of health
care financing, access issues, delivery systems, quality controls,
and related healthcare legislation. (R)
- Requires independent interactions with high level individuals
(CEO, CFO, VP Managed Care) at various provider organizations.
Keywords: CONNECTI CARE, Inc, New York , Senior Provider Contract Specialist, Other , New York, New York
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