Provider Relations Coordinator

2 weeks ago

New York, New York, United States EmblemHealth Full time
Overview

Serve as a crucial intermediary and maintain effective communication between designated facilities, ancillary services, delegated entities, and EmblemHealth.

Oversee daily operations concerning contractual agreements with minimal oversight, focusing on contract enhancement, the rollout of new initiatives, and support for provider-related inquiries, educational resources, and dissemination of Plan guidelines.

Act as the primary contact for escalated matters arising from providers and internal EmblemHealth divisions, including grievances, disputes, and billing issues involving members.

Note:

The term "Provider" encompasses managing entities for healthcare systems, facilities such as specialty clinics, large medical groups, delegated partnerships, ancillary services, and similar organizations.


Key Responsibilities:

  • Aid providers in all aspects of contract disagreements and ensure the prompt and accurate implementation of contract terms and rates.
  • Engage with providers and address their inquiries in a timely, precise, and professional manner with minimal guidance from management.
  • Facilitate the efficient resolution of claim inquiries and complaints for the Hospital, Ancillary, and/or Professional networks; coordinate Joint Operating Committees (JOCs), claims review, and resolution, and support audits as necessary.
  • Assist participating providers when issues necessitate collaboration among various Plan departments (Claims, Care Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, Credentialing, etc.).
  • Provide timely, relevant, and accurate responses to provider requests (including requests for Plan materials, inquiries regarding fees, information from the Plan's Provider Manual, and escalated claim inquiries).
  • Ensure and coordinate the notification and education of various departments within EmblemHealth regarding contract terms and related issues.
  • Oversee delegated credentialing functions and activities.
  • Verify the accuracy of provider demographic information in the Plan's database: review provider data for assigned Providers, manage requests for demographic changes, and investigate discrepancies identified by returned mail or other Plan departments.
  • May engage in recruitment efforts to address Network gaps.
  • Conduct outreach initiatives which may include requests from the Plan's State Sponsored Programs Department for notices, medical record retrieval, and other projects as needed.
  • Document all outreach activities in compliance with departmental standards.
  • Perform additional duties as assigned or required.

Qualifications:

  • Bachelor's degree in a healthcare-related field, Public Administration, or Management.
  • Minimum of four years of direct experience in provider relations.
  • Comprehensive understanding of provider and payer roles, responsibilities, and challenges.
  • Knowledge of healthcare financing, access issues, delivery systems, quality controls, and relevant legislation.
  • Strong customer service skills and the ability to foster excellent relationships with providers and their staff.
  • Ability to collaborate effectively with various Plan departments is essential for success in this role.
  • Exceptional written and verbal communication skills to articulate requests and accurately represent issues for resolution.
  • Strong time management skills and adaptability to handle multiple projects simultaneously, with the ability to shift focus in urgent situations.
  • Interpersonal skills to maintain productive working relationships to resolve issues or gather information, representing the Plan and Department positively.
  • Ability to work independently on assignments and leverage opportunities for support.
  • Analytical and problem-solving skills to identify needs in provider relationships, make recommendations as projects evolve, and follow through to resolution using available resources.
  • Proficiency in Microsoft Excel, Word, and other applications.
  • Strong PC skills, including proficiency in the Microsoft Office Suite.

Additional Information

Requisition ID:

Hiring Range:
$52,000-$92,000

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