Provider Engagement Network Specialist - Hybrid

Summary of Job

Act as a liaison and operate as a vital link between specific Providers and EmblemHealth.  Responsible for day-to-day operations for all activities related to contracts with minimal supervision and direction, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as communication of Plan policies and procedures.  Contact for all escalated issues from the Provider and internal EmblemHealth departments, including grievances, disputes, and provider/member billing complaints.  Note: the term “Provider” can include managing entity for health systems, facilities such as a specialty office, large faculty and group practices, delegated relationships, ancillary or ambulatory centers, value-based relationships, and the like.  

Responsibilities

• Assist providers in all matters related to contract disputes and ensure accurate contract and rate load implementations are done in a timely manner. 
• Communicate with providers and respond to provider inquiries in a timely, accurate, and professional manner with minimal direction from leadership. 
• Support the timely completion/coordination of claim inquiries and complaints for the Hospital, Ancillary, and/or Professional network.  
• 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, and escalated claim inquiries. 
• Lead and facilitate provider meetings to drive resolution of policy, payment, contractual, or other items; including but not limited to Joint or Administrative Operating Committees. 
• Assist participating providers or internal partners 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, Compliance, and Credentialing.  
• Ensure and coordinate notification and education of various departments within EmblemHealth on contract terms and related issues and conditions. 
• Support provider network development initiatives, including network builds, provider recruitment, network expansions. 
• Complete end-to-end contracting process for standard arrangements, including outreach, contract execution, contract loading, and implementation. 
• May recruit available providers to fulfill Network deficiencies. 
• Ensure the accuracy of provider demographic data in the Plan’s database. This includes but is not limited to reviewing provider data for assigned Providers, assisting providers with demographic maintenance and updates, researching provider address discrepancies identified by provider returned mail and potential provider demographic errors identified by other Plan departments or initiatives. 
• Other provider data validation projects as assigned to support strategic network or administrative efficiency initiatives. 
• Ensure regulatory and provider network compliance requirements are met for assigned providers. 
• Coordinate delegated oversight functions and activities. 
• Perform outreach projects which may include requests by the Plan’s State Sponsored Programs Department for DOH, IPRO and DOI notices, HEDIS medical record retrieval and other projects as needed. All outreach documented in compliance with department standards. 
• Perform additional duties as assigned.