EmblemHealth · 1 day ago
Senior Provider Contract Specialist - Hybrid
New York, NY
Contract
Hybrid
Mid, Senior Level
$68K/yr - $119K/yr
4+ years expEmblemHealth is seeking a Senior Provider Contract Specialist to enhance their insurance networks through relationship development with key local network participants. The role involves negotiating contracts, optimizing provider arrangements, and managing day-to-day operations related to contracts and provider issues.
InsuranceNon ProfitWellness
Responsibilities
Recommend innovative contracting strategies to maximize cost containment, access and quality through provider arrangements
Negotiate and communicate contract terms, payment structures, and reimbursement rates to providers
Remain current on provider reimbursement methodologies and identify provider reimbursement trends to assist in the development of provider contracting strategies
Assist providers in all matters related to contract disputes and ensure accurate contract and rate load implementations are done in a timely manner
Communicate independently with providers and respond to provider inquiries in a timely, accurate, and professional manner
Responsible for ongoing network participation and performance, including performance analytics and management, as well as contract renewals and terminations
Analyze financial impact of contracts and terms
Provide timely completion/coordination of claim inquiries and complaints for the Hospital, Ancillary, and/or Professional network. This includes the coordinating of Joint Operating Committees (JOCs), claim review and resolution and support of audits when needed
Responsible for the accuracy of all documentation in support of contracts
Serve participating providers when issues require coordination of various Plan departments. These departments include but are not limited to Claims, Care Management, EDI, Grievance and Appeal, Customer Service, Enrollment, Special Investigations, and Credentialing
Provide timely, useful, and accurate responses to provider requests. This includes but is not limited to provider requests for Plan materials, and provider questions regarding fees, the Plan’s website and IVR, information in the Plan’s Provider Manual, and escalated claim inquiries
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 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. 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
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. All outreach documented in compliance with department standards
Perform additional duties as assigned
Qualification
Required
Bachelors' degree in Health Care-related field, Public Administration, or Management
4 – 6+ years of direct provider relations experience (Required)
Knowledge of provider and payor roles, responsibilities and challenges. An understanding of health care financing, access issues, delivery systems, quality controls, and legislation (Required)
Strong customer service skills and the ability to maintain an excellent rapport with providers and their staff (Required)
Ability to work well with various Plan departments is instrumental in the effectiveness of the position (Required)
Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and that problems are accurately represented for resolution (Required)
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 (Required)
Interpersonal skills to effectively maintain working relationships to get issues resolved or to obtain information through people, and to represent the Plan and the Department in a favorable light (Required)
Ability to work independently assignments and maximize opportunities to support (Required)
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 (Required)
Proficiency testing in Excel, Word and other Microsoft applications (Required)
PC skills including proficiency in Microsoft Office Suite (Required)
Company
EmblemHealth
EmblemHealth is an insurance and wellness company that offers health benefits to consumers, employers, and government purchasers.
1001-5000 employees
H1B Sponsorship
EmblemHealth has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (2)
2023 (2)
2021 (2)
2020 (4)
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