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.


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.

Director, Provider Network Management

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Director and Equivalent
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EmblemHealth
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Summary of Position

Responsible for ensuring overall network compliance with all Plan and regulatory requirements, the processing and management of all provider and vendor contracts, oversight and management of provider directory production. Lead the operational redesign and implementation of priority network projects. Responsible for the development and implementation of department-wide operational process guidelines.
Meet regularly with Legal, Corporate Compliance, and Product Regulatory leadership to share information and discuss issues impacting Provider Network Management.

Responsibilities:

Network Compliance:

  • Provide regulatory leadership and guidance for Network Management activities; operationalizing actions to conform to regulatory requirements.
  • Establish and maintain mutually beneficial relationships with regulatory contacts.
  • Ensure timely responses to regulatory agencies (i.e. NYSDOH, DFS) in response to all network regulatory and compliance inquiries; developing, implementing, and monitoring plans of correction when applicable.
  • Represent Provider Network Management at internal/external regulatory audit interviews.
  • Manage the NYSDOH mandated Hospital/IPA Closure and Termination process.
  • Represent Provider Network Management in all enterprise compliance and regulatory activities such as the Monthly
  • Compliance Committee, Regulatory Compliance Committee, and NCQA Accreditation; leading and implementing any and all initiatives impacting Provider Network Management.
  • Manage and coordinate the timely distribution of all regulatory provider incentives (i.e. QIVAPP).
  • Collaborate with enterprise functional areas to improve processes and communications (i.e. delegation oversight).

Provider Contract Management:

  • Ensure all contracts and implementations are reviewed for compliance with current Provider Contracting Guidelines, processed within department service levels and routed to the appropriate contract configuration staff.
  • Overall responsibility and oversight of enterprise contract repository to include but not limited to assurance of data integrity and monitoring security and access to same.
  • Responsible for security and maintenance of paper contract files.
  • Responsibility for fulfillment of requests for copies of contracts from internal/external customers.
  • Actively participate in all workgroups in which the Provider Network Management Contract Management department is a stakeholder.

Provider Network Redesign:

  • Lead the operational redesign and implementation of priority network projects.
  • Partner with business areas throughout the organization to identify areas of opportunity.
  • Develop work plans and execute plans accordingly.
  • Provider Directory Production.
  • Ensure directories are produced within the required timeframes.
  • Collaborate with business areas to determine and document the directory requirements.
  • Supervise and ensure the development of business requirements for directory production and liaise with the directory production vendor to ensure all requirements are programmed and developed.

Policy/Workflow Development, Training, and Implementation:

  • Responsible for development and implementation of policies, procedures, and workflows for all of Network Management.
  • Ensure annual review of all Network Management operational process guidelines.
  • Educate Provider Network Management department on all and new and revised policies, procedures, and workflows.
  • Identify training needs within the Provider Network Management Department; coordinating training and developing materials to support same.

Six Sigma/Lean Process Improvement Initiatives:

  • Contributes with department wide process improvement initiatives such as leading Lean, Six Sigma Black Belt, and other special projects.
  • Identify areas for improvement and make recommendations to Senior Leadership.
  • Participate in process improvement initiatives in the organization as representative of Provider Network Management.

Qualifications:

  • Bachelor’s degree in Health or Business Administration or a related degree
  • 10+ years in health care or a related field in positions of increasing responsibility
  • Managerial/supervisory experience with processes and/or staff
  • Strong knowledge of provider administration services
  • Ability to organize, prioritize, and effectively manage multiple simultaneous tasks/projects
  • Excellent communication skills (verbal, written, presentation, interpersonal)
  • Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.)
  • Understanding and/or training in Six Sigma and Lean methodology

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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