EmblemHealth · 2 months ago
Senior Provider Engagement Network Specialist - Hybrid
New York, NY
Full-time
Hybrid
Mid, Senior Level
$68K/yr - $119K/yr
4+ years expEmblemHealth is a healthcare company focused on enhancing provider networks through relationship development. The Senior Provider Engagement Network Specialist will be responsible for managing provider contracts, optimizing network performance, and resolving escalated issues while ensuring compliance with regulatory requirements.
InsuranceNon ProfitWellness
Responsibilities
Recommend innovative contracting strategies to maximize cost containment, access, value, and quality through provider arrangements
Negotiate and communicate contract terms, payment structures, and reimbursement rates to providers in alignment with departmental tools; present outliers to leadership as needed
Ensure accurate contract and rate load implementations are done in a timely manner; complete wire forms and track payments as necessary
Remain current on provider reimbursement methodologies and identify provider reimbursement trends to assist in the development of provider contracting strategies
May recruit available providers to fulfill Network deficiencies
Accountable for understanding market trends, competitive information, and governmental models to inform decision-making
Responsible for ongoing network performance, contract renewals, and terminations, including aggregate and product-level performance analytics and management
Analyze financial impact of contract terms through usage of internal tools and collaboration with Healthcare Economics and Contract Configuration; understand and vet complex data in advance of secure distribution to provider organizations and executive leadership teams
Utilize clinical, financial, and quality data to identify and communicate areas of opportunity to the provider entities; collaboratively develop action plans to include targeted goals and interventions to impact these opportunities by coordinating health plan and provider entity resources
Perform contract reconciliations in collaboration with Finance, Capitation, and Quality, and ensure accurate reporting for internal financial reserves, Purchase Orders, and annual plans
Ensure the accuracy of provider demographic data in the Plan’s database. This includes but is not limited to reviewing provider data for assigned Providers, 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
Communicate independently with providers and respond to provider inquiries in a timely, accurate, and professional manner; educate and direct provider to self-service tools
Serve as subject matter expert to assist internal and external contacts in all matters related to the contract, including payment policy, performance, attribution, and data accuracy. Track all contract terms via contract summaries
Lead resolution of complex issues requiring coordination of various Plan departments. These departments include but are not limited to Claims, Care Management, EDI, Quality, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, Compliance, Operations, Product, Sales, and Credentialing. Optimize interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships
Ensure and coordinate notification and education of various departments within EmblemHealth on contract terms and related issues and conditions
Lead and facilitate provider meetings to drive resolution of policy, payment, contractual, or other items; including but not limited to Joint or Administrative Operating Committees. Coordinate and facilitate all internal and external meetings related to contract performance, consistent with contract stipulations
Assure regulatory and provider network compliance requirements are met for assigned providers
Coordinate delegated credentialing functions and activities
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. All outreach documented in compliance with department standards
Coach new and less experienced Specialists, as needed
Perform additional duties as assigned
Qualification
Required
Bachelor's degree in Health Care-related field, Public Administration, or Management
4 – 6+ years of relevant, professional work experience (Required)
3+ years' experience in healthcare analytics, contracting or plan or provider operations, or related (Required)
Additional experience/specialized training may be considered in lieu of educational requirements (Required)
Demonstrated understanding of standard analytic methodologies and tools (Required)
Excellent organizational, project management, and relationship management skills (Required)
Excellent communication skills - verbal, written, presentation, interpersonal with all types/levels of audience (Required)
Proficiency with MS Office - Word, Excel, PowerPoint, Teams, Outlook, etc. (Required)
Understanding of the clinical, economic, and quality components of healthcare (Required)
Company
EmblemHealth
EmblemHealth is an insurance and wellness company that offers health benefits to consumers, employers, and government purchasers.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
M
Michael Collins
Vice President CRM Applications
Recent News
Behavioral Health Business
2026-01-11
2025-12-10
bloomberglaw.com
2025-12-06
Company data provided by crunchbase