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.
- Bachelor’s degree
- Masters Degree preferred
- 4- 6 years experience in network management related role, such as contracting or provider service required
- Knowledge of provider contracting methodology and payor roles, responsibilities and challenges required
- Understanding of health care financing, access issues, delivery systems, quality controls, and related healthcare legislation required
- 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 required
- Requires independent interactions with high level individuals (CEO, CFO, VP Managed Care) at various provider organizations required
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.