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.

Senior Delegate Relations Specialist

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Manager & Professional
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190EC Requisition #
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Supports the Director of Risk Contracting in the management of the Montefiore IPA and St. Barnabas contracts. Monitors and administers specific requirements of the contract as they relate to Claims Delegation, electronic transactions, information systems, Credentialing, Customer Service and Provider Relations.

Responsibilities:
  • Manages weekly IPA Credentialing updates, monitors provider record and contract set up including validating accuracy of all requests and resolving discrepancies.  Completes PCP Panel moves requests to Provider Mods for Montefiore and St. Barnabas.  Manages auto assignment table for Montefiore.
  • Schedules, prepares agenda, documents minutes and guides/facilitates, bringing business decisions to closure, tracks to closure deliverables for the monthly Administrative Oversight Committee Meeting for the Risk Entities and the Finance Administrative Oversight Committee Meetings.
  • Coordinates with all functional areas involved, annual Emblem audits and regulatory audits including reviewing audit requests, obtaining clarification, scheduling, audit documentation requests, communications and distribution of due diligence materials for all delegated functions, including but not limited to:  Appeals, Claims, Credentialing, Customer Service, UM, Case Management, Disease Management, and Behavioral Health.
  • Capitation Error Reports and Capitation Dispute files.   Works monthly capitation error reports and capitation dispute, CPTM and 50/50 files.  Tracks chargebacks for revenue maximization programs.  Coordinates with finance as applicable.
  • Coordinates with Subject Matter Experts and delegate, obtaining clarification on regulatory requirements, monitors and brings to closure Improvement Action Plans issued for delegated functions as applicable.  Develops and implements new work flows to maintain compliance.  Escalates items using business judgment.
  • Responsible for research and closure of ESAWS cases, identifying core issues and resolving for member.  Prepares proposal for PPM if systems issue is identified as a root cause.
  • Responsible to implement monthly monitoring reports to identify issues in provider record that impact capitation and resolve those issues. This applies to both Qcare and FACETS and include monitoring of enrollment reports to identify incorrect risk/non risk tagging.
  • Coordinates with delegate regarding provider education, resolution to complaints.
  • Responsible for distribution and posting of Monthly Reports to Delegation Sharepoint Drive.  Responsible for communication of and overseeing implementation or reporting requirement changes, leads meetings between SME and Delegate to clarify report requests, measurement detail and calculation.  Tailors Generic Reporting Requirement Exhibit to reflect only those requirements that contractually delegated to the applicable Delegate.
  • Tracks and facilitates resolution to Corrective Action Plans (CAP) for Credentialing and Customer Service as applicable.
  • Maintains Quarterly Provider Reserve Files.
  • Performs other duties and projects as assigned or required.

Qualifications:

  • Bachelor’s Degree in Health Care related field; Master’s Degree preferred

  • Minimum of 4 – 6 years’ experience of increasing responsibility in Provider Services or Network Development positions required

  • Proficiency in word processing, spreadsheets, and database applications 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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