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.

Lead Provider Relations Coordinator

📁
Manager & Professional
📅
190GZ Requisition #
Sign Up for Job Alerts
The Provider Relations Lead Coordinator acts as a liaison between designated High Touch clinicians and the Plan for GHI, HIP and Emblem Health through field activity related to provider recruitment, education and service.  The Provider Relations Lead Coordinator will conduct a minimum of bi-annual on-site visits with designated High Touch clinicians to assist with provider issues, education materials, communication of Plan policies and procedures, and Plan strategic initiatives.  The Lead Coordinator also handles all contracting initiatives associated with the designated High Touch clinicians.

Responsibilities:
  • Communication of Plan policies and procedures, contract terms and conditions, and Plan strategic initiatives to participating providers and ongoing monitoring and re-education to ensure adherence.  This includes but is not limited to orientations, re-orientations, routine service calls, industry conferences/fairs, Plan initiatives such as EDI, and access and availability, and provider re-education as necessary due to issues identified by other Plan departments such as Customer Service, Quality Management, Care Management, Special Investigations and Grievance and Appeal.
  • Recruit and retain providers as needed to comply with the Plan’s provider access policies and procedures.  This includes responding to provider requests to join the Plan, recruitment initiatives, requests for providers from other Plan departments and members, assistance with re-credentialing activities, submission of complete applications/site visits/contracts, attempts to retain providers who may wish to terminate, and identifying areas of network need and recruiting to meet that need.
  • Assist participating providers when issues require coordination of various Plan departments.  These departments include but are not limited to Claims, Care Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, and Credentialing.  Provide timely, useful, and accurate responses to provider requests.  This includes but is not limited to provider requests for Plan materials, and provider questions regarding fees, the Plan’s website and IVR, information in the Plan’s Provider Manual/Practitioner Handbook, and escalated claim inquiries.
  • Ensure the accuracy of provider demographic data in the Plan’s database.  This includes but is not limited to reviewing provider data for assigned service area, proofreading directory draft, handling provider requests for demographic changes, researching provider address discrepancies identified by provider returned mail and potential provider demographic errors identified by other Plan departments or initiatives. 
  • Timely completion of outreach projects.  This includes but is not limited to, requests by the Plan’s Government Programs Department for DOH, IPRO, and DOI notices and requests by Quality Management for medical record retrieval projects such as HEDIS.  Assist Provider Relations Management with special projects.
  • Recommend innovative contracting strategies to maximize cost containment, access and quality through provider arrangements.  Identify provider reimbursement trends to assist in the development of provider contracting strategies.  Analyze provider requests for enhanced fees, provide recommendations to management, and modify contract and fee schedule if necessary at direction of management.
  • Provider visit forms/reports, SAWS provider and member centric documentation, project reports, and any other routine updates regarding assigned territory as scheduled.
  • Assist in the development of materials necessary for provider education, orientation, and training. Assist with training new Provider Relations Lead Coordinator.
Qualifications:
  • A Bachelors degree in Health Care related field, Public Administration, or Management desired
  • Masters Degree a plus
  • Three years of direct provider relations field experience required
  • Knowledge of provider and payor roles, responsibilities and challenges.  An understanding of health care financing, access issues, delivery systems, quality controls, and legislation required
  • Strong customer service skills and the ability to maintain an excellent rapport with providers and their staff required
  • Ability to work well with various Plan departments is instrumental in the effectiveness of the position required
  • Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and that problems are accurately represented for resolution required
  • Time management skills and flexibility to work on multiple projects/assignments simultaneously, with ability to change focus in a crisis situation.  Willingness to assume diverse duties and challenges required
  • Interpersonal skills to effectively maintain working relationships to get issues resolved or to obtain information through people, and to represent the Plan and the Department in a favorable light required
  • Ability to work independently on field assignments and maximize opportunities to support providers on site.  Willingness to spend majority of time in field, as opposed to office required
  • Analytical and problem solving skills to identify needs in provider relationships, make recommendations as projects develop and follow through to resolution using available resources to achieve a solution required
  • Proficiency testing in Excel, Word and other Microsoft applications required
  • PC skills including proficiency in email, database application 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.

Previous Job Searches

Please try again.

Oops!

Either there was a problem on our end with the action you just performed, or we are currently having technical difficulties with our system. Please try again later.