Director, Provider Relations

Summary:

• Responsible for developing and executing network and contracting strategy with senior leadership.
• Identify and negotiate financially beneficial terms to support business and clinical initiatives to continually advance network relationships and manage the medical trend.
• Ensure that the competitive contractual engagements translate into competitive rates for customers, leading to increased membership growth.
• Direct programs to resolve root cause claims/operational issues; educate providers on EH policies, procedures & processes.

Responsibilities:

• Develop and lead quality relationships with providers.
• Accountable for significant hospital and physician network contract negotiations, including leadership and oversight of the negotiation process, ensuring contracts are negotiated and maintained at optimum cost/benefit levels.
• Lead ongoing contract maintenance and resolution of business issues associated with contract terms, including financial settlements, provider reporting, etc.
• Assess financial impact of contractual rates and recommend rate corridors.
• Lead contracting team to ensure complete understanding of current contractual terms and communicate issues that may arise as the contract term is renewed.
• Partner with operational areas such as UM, Claims, Medical Management, Quality and GAD to ensure compliance with facility agreements. Assemble Joint Operating Committee and Joint Workgroup, including structure, processes, documentation and membership.
• Develop and coordinate overall contracting and contract-specific strategies and recommendations; translate provider strategies into tactical and accountable plans. Lead quarterly meetings with strategic provider partners to review performance and recommend initiatives to strengthen our partnerships.
• In collaboration with key internal collaborators, establish a measurable plan to lead the development and implementation of advanced and emerging provider network contract models and reimbursement methodologies with providers in the EmblemHealth network.
• Maintain contracting calendars and/or a contract dashboard to ensure adherence to key contract dates/timelines related to contract requirements, adjustment and/or renewals.
• Contract with physicians and practitioners for all PPO and HMO lines of business including government programs.
• Oversee contracting of all pathologists, anesthesiologist, radiologist and ER physician groups.
• Develop processes and practices to ensure that contracts and supporting documentation are compliant with legal and regulatory requirements, completed within leadership determined timelines and that contract terms are accurately articulated for implementation purposes.
• Obtain documentation for credentialing; collect data pertaining to NY State Health Provider Network (PNDS) reporting.
• Lead, coach, train, develop, and manage staff to ensure corporate and department goals and objectives are met.
• Special projects as assigned.
• Perform other related tasks as directed, assigned, or required.