Provider Contract Specialist

Summary of Job - Hybrid

Act as a liaison and operate as a vital link between specific Facility, Ancillary, Delegated and/or Professional 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 contact for all escalated issues from the Provider and internal EmblemHealth departments, including grievances, disputes, and provider/member billing complaints.

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; coordinate Joint Operating Committees (JOCs), claim review and resolution and support of audits when needed.
• Assist participating providers when issues require coordination of various Plan departments (Claims, Care Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, Credentialing, etc.).
• Provide timely, useful, and accurate responses to provider requests (provider requests for Plan materials; provider questions regarding fees, the Plan's website and IVR; information in the Plan's Provider Manual, and escalated claim inquiries.
• Ensure and coordinate notification and education of various departments within the EH on contract terms and related issues and conditions.
• Coordinate delegated credentialing functions and activities.
• Ensure the accuracy of provider demographic data in the Plan's database: review provider data for assigned Providers; handle provider requests for demographic changes; research provider address discrepancies identified by provider returned mail and potential provider demographic errors identified by other Plan departments or initiatives.
• May recruit available providers to fulfill Network deficiencies.
• 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.
• Document all outreach activities in compliance with department standards.
• Perform additional duties as directed, assigned, or required.