Mgr., Provider Operations
EmblemHealth - New York, NY

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The basic function of the Manager, Provider File Operations is to manage the staff responsible for provider file data and to assist with the development, implementation and maintenance of professional and ancillary provider data as it exists within the Consolidated Provider File and QCARE.

Principal Accountabilities:

A. Ensure all direct reports adhere to the below in a timely and accurate fashion in accordance with current PFO guidelines.

1. CPF Provider File Database Maintenance.
a) Add new providers to CPF provider file
b) Add new tax ids to CPF provider file
c) Add/modify existing CPF provider reimbursement contract linkages
d) Add/modify provider demographic changes
e) Analyze/modify CPF reflect provider status changes
f) Liaison to Relationship Managers
g) Analyze/document data sets
h) Verify provider data via web based regulatory agency portals
i ) Creation/mailing/documentation of specific provider notifications
j ) Outreach to provider to verify data submissions
k) Research and create provider records to resolve claims issues
l ) Analyze data submissions to determine appropriateness of change in CPF
m) Analyze data submission to determine Primary Contract Affiliation

2. Track, receipt and execution of provider file updates.
3. Provide timely, effective and accurate responses to provider data issues raised by providers and facilities, according to established departmental thresholds.
4. Communications of HIP provider file policies to affiliated and non-affiliated providers.
5. Assist in the recommendation of innovative workflow strategies to maximize efficiency and effectiveness. Includes application of Six Sigma and Lean fundamentals for improvement to accuracy and timeliness.
6. Assist in translating physician contracts to the appropriate CPT4 codes; subsequently loading the codes, fee schedules and medical policy to the Qcare mainframe.
7. Provide representation to the provider community on behalf of the Department, to respond to requests for assistance with issues relating to reimbursement, issues requiring internal HIP coordination and enhancements to existing communications to groups.
8. Development, implementation and testing of CPF enhancements and data loads to CPF when warranted.
9. Interact with other areas of the organization to support contractual arrangements.
10.Provide complete and timely inventory levels for departmental goals and individual metrics.

Education and Experience:

- Knowledge of healthcare industry delivery systems is essential.

- The continual adherence to PFO departmental quotas and designated TAT for all deliverables while maintaining regulatory and SOX audit results within acceptable parameters.

- Knowledge of provider reimbursement methodology is essential.

- Analytical skills and an ability to evaluate and solve problems are essential.

- Knowledge of governmental regulations as they relate to provider reimbursement is desired.

- Excellent oral and written communication skills are required in order to effectively represent the Provider - Operations Department within HIP.

- Managerial and organizational skills are required in order to effectively supervise staff, maximize productivity, foster initiative and achieve departmental goals.

- The ability to develop and prioritize departmental goals and effectively utilize staff in order to attain those goals is essential.

- Working knowledge of Microsoft access and Microsoft Excel

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EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...