Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Assistant Vice President, Facility Contracting

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Professional / Leadership
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190TN Requisition #
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Lead facility network support for all product lines of the business from four perspectives – unit cost control, quality outcomes, consumer access and competitiveness. Define and provide governance and compliance processes for professional, ancillary and facility contracting including oversight and management of over 160,000 Professional, Facility and Ancillary contracts as well as bringing uniformity, efficiencies and consistency in the areas of facility network contracting, training and development of the staff.  Manage all DRG validation processes and related reimbursement (APG, APC) implementation.  Maintain strong relationships to ensure that contracting activities are aligned with corporate objectives and are well executed.

Responsibilities:
  • Oversee the activities of the Provider Relations field and in-house Coordinators, including education, recruitment, project outreach, site visits, orientations/reorientations, and regular service visits. 
  • Manage and train staff to ensure superior provider education/communication of Plan policies and procedures, contract terms & conditions and Plan strategic initiatives, provider problem resolution, and optimal representation of the Plan in the provider community.  
  • Develop and accompany staff in the field to monitor service on a regular basis.  
  • Develop and provide training of all staff on QCARE, CPF, SAWS, PRS, Plan policies and procedures, and regulatory and business changes that impact Provider Relations.  
  • Track, trend and report field activity with dashboards.
  • Collaborate with various Plan departments to resolve escalated issues with providers, including but not limited to provider requests for Plan materials, provider questions regarding contracts and fees, the Plan’s website and IVR, information in the Plan’s Practitioner Manual, and claim inquiries.  
  • Assist other departments with inquiries related to providers, including but not limited to questions regarding par status, member complaint resolution, and requests for provider recruitment for: Relationship Managers, Claims, Care Management, Quality Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Marketing, Special Investigations, Credentialing, Provider File Operations, and Provider Communications.  
  • Negotiate complex, competitive contractual relationships with providers and restructure existing contracts as needed to control unit costs and provide adequate network access.
  • Define and direct innovative contracting strategies to maximize cost containment, access and quality through provider arrangements.  
  • Identify provider reimbursement trends to develop provider contracting strategies.  
  • Analyze and project provider requests for enhanced fees, provide recommendations to management, modify contract and fee schedule if necessary at direction of management, and ensure correct loading in system with Provider File Operations. 
  • Represent department at internal and external meetings with providers, or other Plan departments.  
  • Initiate and lead large provider group orientations and question and answer meetings, individual provider meetings, interdepartmental Plan meetings, and industry conferences/fairs. 
  • Prepare and maintain departmental policy and procedure manuals, and forms.  Provide input and support in the preparation of provider updates, communications, manuals, directories and education materials. 
Qualifications:
  • A Bachelor’s degree in Health, Public Administration, Management, or related equivalent; Master’s preferred
  • Current, unrestricted driver’s license or ability to travel via NYC mass transit system
  • At least 12+ years of relevant professional work experience in positions of progressively increasing responsibility required
  • 4 - 6 years’ experience in provider relations, provider reimbursement, health care administration or related field required
  • Proven experience in effective staff management including training, developing, mentoring, and managing performance required
  • In-depth understanding of healthcare service provider networks, policies, procedures, workflows, and regulations required
  • Ability to identify opportunities to achieve higher levels of efficiency; to develop recommendations to achieve related goals; and to effectively communicate them in order to maximize chances for implementation and success required
  • Ability to maintain both detail orientation and “big picture” strategic overview required
  • Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and that problems are accurately represented for resolution required
  • Proficient in MS Office applications (word processing, database/spreadsheet, e-mail, presentation) required
  • Database application proficiency a plus; preferred

EEOC Statement

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.

Sponsorship Statement

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.

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