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Senior Provider Contract Specialist

Location: New York
Posted on: November 22, 2021

Job Description:

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 negotiations.
  • 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 adequacy.
  • Obtains documentation for credentialing and collects data pertaining NY State Health Provider Network (HPN) reporting Qualifications:
    • 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 legislation.(R)
    • 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. (R)

Keywords: CONNECTI CARE, Inc, New York , Senior Provider Contract Specialist, Other , New York, New York

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