Responsible for provider network development, contracting, network servicing, management of Provider Relations field Coordinators and other staff, assistance to other Plan departments for inquiries related to providers, and assistance with development of internal policies and procedures for GHI, HIP, and EmblemHealth. Provides support and direction to staff to ensure optimal provider recruitment, education, and service, completion of Plan initiatives, and the establishment of an adequate panel of providers for medical care that meets member geographic, cultural, and linguistic needs with cost effective contracts. Take overall responsibility for provider performance management. Advance EmblemHealth in the provider market through a positive provider experience by furthering the goals important to practices including administrative ease, quality and risk score improvement (QIP), cost efficiency, VBP and practice management. Represent and advance Emblem’s interests in the provider market as the preferred plan through superior customer service and execution of provider engagement strategies. Develop and manage a high performance network and utilize various provider strategies that follow four core principles: Provider and Member Engagement, Quality/Risk Score Improvement, Administrative Efficiency and Cost Effectiveness.
- Oversee the activities of the Provider Relations field and in house Coordinators, including education, recruitment, project outreach, site visits, orientations/reorientations, and regular service visits.
- Manage and train staff to ensure superior provider education/communication of Plan policies and procedures, contract terms & conditions and Plan strategic initiatives, provider problem resolution, and optimal representation of the Plan in the provider community.
- Accompany staff in the field to monitor service on a regular basis. Ensure training of all staff on QCARE, CPF, SAWS, PRS, Plan policies and procedures, and regulatory and business changes that impact Provider Relations. Track, trend and report field activity.
- Coordinate participating providers on escalated issues that require involvement of various Plan departments, including but is not limited to provider requests for Plan materials, provider questions regarding contracts and fees, the Plan’s website and IVR, information in the Plan’s Practitioner Manual, and claim inquiries.
- Work with other departments to resolve inquiries related to providers, including questions regarding par status, member complaint resolution, and requests for provider recruitment.
- Provide answers to questions about providers and provide needed support to staff across the enterprise, including Relationship Managers, Claims, Care Management, Quality Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Marketing, Special Investigations, Credentialing, Provider File Operations, and Provider Communications.
- 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, modify contract and fee schedule if necessary at direction of management, and ensure correct loading in system with Provider File Operations.
- Follow up on all provider issues, questions, inquiries and facilitate resolution.
- Work collaboratively with internal departments to facilitate resolution as needed.
- Demonstrate a clear understanding of EmblemHealth’s model, its supporting systems, and how they impact provider practices.
- Apply critical thinking skills to solve problems with logical and analytical discipline.
- Facilitate regular meetings with providers and other follow-up meetings with internal departments.
- Ensure that decisions from external partner meetings are appropriately implemented to meet or exceed goals and expectations.
- Represent department at internal and external meetings with providers, or other Plan departments. This includes but is not limited to large provider group orientations and question and answer meetings, individual provider meetings, interdepartmental Plan meetings, and industry conferences/fairs.
- Identify and resolve critical bottlenecks to agreed-upon contractual obligations and negotiated deliverables while providing succinct reporting to executive leadership.
- Collaborate and coordinate with Operations, Clinical, Finance and Sales, and other functional areas in the execution of all contractual or negotiated deliverables.
- Performs other job-related duties as required.