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.

Director, Provider Network Management

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Director and Equivalent
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200FC Requisition #
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Negotiate, implement and manage competitive contractual relationships with physicians, hospitals, ancillary providers, IPAs and health systems to achieve Provider Network and customer needs.  Lead provider innovation, initiatives and network strategies including network provider pricing/fee schedules, cost optimization, trend analysis, Provider Network improvement opportunities, value-based contracting, provider incentive programs and other strategies while continuously improving quality, access and customer satisfaction; exhibiting insight, innovation and leadership.  Maintain accountability for specific medical cost initiatives with an emphasis on executing productive provider contracts.  Serve as liaison between the organization, hospital  physician, IPA and ancillary leaders to develop, communicate, and execute strategic direction.  Build relationships with internal senior stakeholders to align objectives, develop strategy, and maximize outcomes; work cross-functionally to integrate Provider Network plans, activities and policies throughout the enterprise to meet corporate objectives.  Direct and supervise Network staff in operations and relationship management associated with Enterprise goals.  Develop and implement Provider Network innovation and optimization standards and guidelines to increase market share, revenue growth, and quality outcomes.

Responsibilities:
  • Contract Management 
    • Lead strategic provider relationships which includes negotiating, implementing and maintaining some of the most competitive and complex contracts with large health systems, hospital partners, physicians, IPA, ancillary providers and other provider entities.
    • Oversee staff that has day to day responsibility for managing the relationships that supports the EmblemHealth Provider Network, serving as escalation point for internal staff and external contacts regarding resolution of highly complex or unusual business problems that affect major contract functions, performance or relationships. 
    • Meet regularly with providers at Joint Oversight Committee meetings to address all financial, operational, quality and contractual issues.
    • Participate in workgroups in which the Provider Network department is a stakeholder.
  • Financial Reporting
    • Maintain Provider Support reserves for all contracts managed.
    • Attend routine Finance/Actuary meetings and report Provider Network updates.
    • Develop executive financial dashboards and reports reflecting underpayment and overpayment activities and payment trends.
    • Lead the provider settlement process.
  • Department Policy/Workflow Development, Training, and Implementation 
    • Work within the guidelines outlined in the Provider Network Contracting End to End process (planning, negotiation, and implementation phases) to develop contracting strategies, evaluate the current performance of contracts, assist in forming the model to evaluate and proposals or counter proposals received or sent to hospitals, facilities and any type of providers; evaluate impact of reimbursement rates and/or methodologies.
    • Implement strategies to achieve financial targets.
    • Develop and implement policies, procedures, and workflows for Provider Network department and all types of providers.
    • Identify training needs within the Department and external providers; coordinating training and developing materials to support same.
    • Staff development and training as needed to maintain efficient operations and growth.
  • Strategic Projects
    • Responsible for implementation of HCCI or other Provider Network projects as assigned by leadership.
    • Manage strategic positioning for provider contracting, identifying and acting upon opportunities for greater value-orientation and/or other business/network development opportunities.
    • Stay attuned to industry and market trends and research on best practices and initiatives in developing new and innovative payment and network models that support quality-driven health care. 
  • Network Compliance
    • Ensure Provider Network contract compliance with all Plan and regulatory requirements.
    • Ensure timely responses to regulatory agencies (i.e. NYSDOH, DFS) in response to all Provider Network regulatory and compliance inquiries.
Qualifications:
  • Bachelor’s degree in Health or Business Administration or a related field required
  • Master’s degree preferred (MBA, MPH, MA)
  • 10+ years’ experience in the health care industry with increasing responsibility including staff management required
  • 10+ years' prior experience (contracting, provider and/or vendor management) required
  • Staff management experience preferred
  • Familiarity with provider community and health care marketplace trends and superior knowledge of NYS hospital reimbursement and managed care laws and regulations required
  • Network management, provider/facility service and contracting experience required
  • Strong quantitative skills including the ability to identify trends, analyze and interpret financial and utilization data required
  • Outstanding oral and written communication skills required
  • History of demonstrating initiative and out-of-the-box thinking along with the flexibility to implement change quickly required

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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