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Hospital Contract Specialist

EmblemHealth New York Full-Time
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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:

  • 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

Recommended skills

Claims
Credentialing
Health Care
Methodologies
Finance
Managed Care
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Job ID: 190OW

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EmblemHealth is
a local, neighborhood health plan that has served the New York City area and
surrounding communities for more than 75 years. That’s the kind of experience
that makes us unique. We’re proud to be one of the nation’s largest
not-for-profit health plans, serving 3.1 million people who live and work
across the New York tristate area.

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