The Sr. Provider Network Coordinator operates as a vital link between Very Important Low Touch clinicians for EmblemHealth, and its affiliated Plan partners, by establishing effective communication through outbound telephone calls and clinician correspondence to provide information on contract terms and conditions, education on new products or product enhancements, Plan(s) initiatives, policies and procedures and related questions or issues. The Sr. Provider Network Coordinator is the lead contact for all escalated compliance issues, grievances and disputes and member billing complaints. In addition, the Provider Relations Senior Coordinator will coordinate and conduct quarterly (frequency varies by locality) Provider Forum meetings to service and educate the Low Touch clinicians on the Plans of GHI, HIP and EmblemHealth. The Senior Coordinator is also responsible for attending convention/conferences and conduct in-person visits upon request. The Senior Coordinator will support the Lead Coordinator with research of the clinician issues and provide feedback. All corporate contracting initiatives will be handled by the Provider Relations Senior Coordinator. The Senior Coordinator completes HEDIS medical record retrieval and other projects as needed. The majority of functions of this position will be conducted in-house.
• Facilitate response of clinician issues from all outbound telephone calls and clinician correspondence made by or sent by Very Important Low Touch clinicians. Collaborate with internal staff to facilitate timely resolution of Low Touch clinician escalated compliance issues, grievances, disputes and member billing complaints. The Senior Coordinator will coordinate issues referred by Lead Coordinator. Upon request, the Senior Coordinator will conduct on-site service and orientation visits for Very Important Low Touch and Self Service clinicians. All contact document in compliance with department standards. Negotiation and retention of Very important Low Touch clinician(s) including responding to requests to join the Plan(s), recruitment initiatives and request for clinician(s) participation from other Plan department(s) and members. Work in partnership with Credentialing Department on activities relating to Very Important Low Touch clinicians such as the submission of completed applications, site visits, contracts and materials related to credentialing necessary to comply with Plan standards. All contact documented in compliance with department standards. Affirm quarterly Provider Forums to service and educate Very Important Low Touch clinicians on new products or product enhancements for GHI, GHIHMO, HIP and EmblemHealth. Through effective calendaring and time management skills. In addition, educate clinicians on Plan(s) initiatives, policies and procedures and related questions or issues. Attend conventions and conferences to educate clinician community. All contact documented in compliance with department standards.
• Ensure the accuracy of Very Important Low Touch clinician(s) demographic data in the Plan(s) database. This includes reviewing provider data for assigned service area, proofreading directory draft, handling provider requests for demographic changes, researching provider address discrepancies identified by provider returned mail and potential provider demographic errors identified by other Plan departments or initiatives.
• Perform outreach projects as related to Most Important Low Touch clinicians. This includes requests by the Plan’s Government Programs Department for DOH, IPRO and DOI notices. In addition, performs HEDIS medical record retrieval and other projects as needed. All outreach documented in compliance with department standards.
• Aid in the development of materials necessary for provider education, orientation and training. Assist with training new Provider Relations Senior coordinators.
Knowledge, Skills & Abilities:
The ability to take initiative when there is potential for improvement in either the financial or operational relationship between the Plan and a participating provider. The incumbent will offer solutions and explore options to support recommendations and work directly with providers to implement. If there is an opportunity to resolve a provider problem, independent action will be expected. Discretion is essential in dealing with provider relationships and reimbursement issues. Assist other provider relations teams as needed.
• Minimum of three years of direct provider relations field experience. A Bachelor’s degree in Health Care related field, Public Administration, or Management preferred. Master’s Degree a plus.
• Knowledge of provider and payor roles, responsibilities and challenges. An understanding of health care finance, access issues, delivery systems, quality controls, and legislation
• Strong customer service skills and the ability to maintain an excellent rapport with providers and their staff
• Ability to work well with various plan departments is instrumental in the effectiveness of the position
• Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and the problems are accurately represented for resolution
• Time management skills and flexibility to work on multiple projects/assignments simultaneously, with ability to change focus in a crisis situation. Willingness to assume diverse duties and challenges
• Interpersonal skills to effectively maintain working relationships to get issues resolved
• Represent the plan and the department in a favorable light
• Ability to work independently on assignments and maximize opportunities to support providers. Willingness to spend some time in the field, as opposed to office
• Analytical and problem solving skills to identify needs in provider relationships, make recommendations as
projects develop and follow through to resolution using available resources to achieve a solution
• PC skills including proficiency in e-mail, spreadsheets, and word processing, Database application proficiency a plus
• Current, unrestricted driver’s license and access to a car
EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...