Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
Director, Provider Relations
Summary:
- Responsible for developing and executing network and contracting strategy with senior leadership.
- Identify and negotiate financially beneficial terms to support business and clinical initiatives to continually advance network relationships and manage the medical trend.
- Ensure that the competitive contractual engagements translate into competitive rates for customers, leading to increased membership growth.
- Direct programs to resolve root cause claims/operational issues; educate providers on EH policies, procedures & processes.
Responsibilities:
- Develop and lead quality relationships with providers.
- Accountable for significant hospital and physician network contract negotiations, including leadership and oversight of the negotiation process, ensuring contracts are negotiated and maintained at optimum cost/benefit levels.
- Lead ongoing contract maintenance and resolution of business issues associated with contract terms, including financial settlements, provider reporting, etc.
- Assess financial impact of contractual rates and recommend rate corridors.
- Lead contracting team to ensure complete understanding of current contractual terms and communicate issues that may arise as the contract term is renewed.
- Partner with operational areas such as UM, Claims, Medical Management, Quality and GAD to ensure compliance with facility agreements. Assemble Joint Operating Committee and Joint Workgroup, including structure, processes, documentation and membership.
- Develop and coordinate overall contracting and contract-specific strategies and recommendations; translate provider strategies into tactical and accountable plans. Lead quarterly meetings with strategic provider partners to review performance and recommend initiatives to strengthen our partnerships.
- In collaboration with key internal collaborators, establish a measurable plan to lead the development and implementation of advanced and emerging provider network contract models and reimbursement methodologies with providers in the EmblemHealth network.
- Maintain contracting calendars and/or a contract dashboard to ensure adherence to key contract dates/timelines related to contract requirements, adjustment and/or renewals.
- Contract with physicians and practitioners for all PPO and HMO lines of business including government programs.
- Oversee contracting of all pathologists, anesthesiologist, radiologist and ER physician groups.
- Develop processes and practices to ensure that contracts and supporting documentation are compliant with legal and regulatory requirements, completed within leadership determined timelines and that contract terms are accurately articulated for implementation purposes.
- Obtain documentation for credentialing; collect data pertaining to NY State Health Provider Network (PNDS) reporting.
- Lead, coach, train, develop, and manage staff to ensure corporate and department goals and objectives are met.
- Special projects as assigned.
- Perform other related tasks as directed, assigned, or required.
Requirements:
- BS in Business Administration, Health Care Administration, Finance or related; Master’s preferred
- 10 – 12+ years of relevant, professional work experience required
- 5 – 8+ years of experience with managed care, health administration or health education and contracting, provider and/or vendor management required
- Expert level understanding of contract terms, SLAs, metrics, etc. required
- Understanding of applicable regulations related to healthcare required
- Excellent communication skills (verbal, written, presentation, interpersonal, negotiations) required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
- Prioritizing and organizing skills; outstanding attention to detail required
- Proven track record of successfully managing multiple tasks/projects with conflicting priorities/deadlines required
- Proven staff and process management experience required
- Willingness and ability to physically travel to various sites as needed required
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
EmblemHealth may provide work visa sponsorship depending on factors such as business unit requirements, position nature, costs, and applicable laws and regulations.