Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Out of Network Contract Specialist-Remote
Summary of Job
Responsible for day-to-day operations for all activities related to out-of-network negotiations, such as negotiating pre- and post-service Single Case Agreements (SCAs) on claims authorized on behalf of EmblemHealth's network as well as out-of network Agreements. Act as a liaison and operate as a vital link between specific out-of-network Facility, Ancillary, Delegated and/or Professional providers and EmblemHealth as it relates to out-of-network Agreements.
Responsibilities
- Determine appropriate action on a case-by-case basis for out-of-network claims: analyze the costs vs. benefits for individual cases in order to provide a meaningful balance between costs to the company and members’ well-being.
- Balance conflicting requests and obtain appropriate resolutions within EmblemHealth’s guidelines.
- Contribute to corporate cost containment efforts by negotiating single case agreements on pre- and post-service claims for authorized services rendered by providers who are out of EmblemHealth’s network.
- Partner with G&A for out-of-network providers: respond to appeals; analyze individual claims; prepare materials and negotiate to provide resolution for the appeal.
- Maintain detailed and accurate data for all SCAs for payment trend analysis and future contract negotiations.
- Provide information and recommendations that help to identify patterns and trends.
- Provide timely, useful, and accurate responses to internal and external requests (provider requests for Open Negotiation via IDR/NSA process, Grievance & Appeals team requests for details surrounding a case, Utilization/Care Management requests to initiate a Single Case Agreement and escalated claim inquiries related to a Single Case Agreement or Open Negotiation).
- Communicate with providers and internal departments to respond to inquiries in a timely, accurate, and professional manner with minimal direction from leadership.
- Analyze, research, and resolve complex claims inquiries pertaining to negotiated Single Case Agreements according to the line of business and members’ benefit plan.
- Audit Single Case Agreement ensuring proper payments are made to satisfy Annual Internal Audit reviews.
- Participate in special projects related to out-of-network negotiations by coordinating with Provider Network Management, Grievance & Appeals and other departments.
- Support and assist Out of Network Negotiations Manager, in preparing monthly performance reports for senior management.
Qualifications
- Bachelor’s degree.
- 3 – 5+ years of relevant, professional work experience, preferably in Claims (Required)
- Excellent customer service skills with a high degree of timely problem resolution (Required)
- Ability to work well with various Plan departments is instrumental in the effectiveness of the position (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)
- Strong communication skills (verbal, written, interpersonal, negotiation, interpretation); ability to ensure that requests are articulated and that problems are accurately represented for resolution (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 effectively both independently and as part of a team (Required)
- Mathematical and analytical skills; and the ability to identify and interpret trends and patterns (Required)
- Ability to organize, prioritize, and effectively manage multiple tasks with conflicting/overlapping deadlines (Required)
- Proficiency with MS Office - Word, Excel, Access, PowerPoint, Outlook, Teams, SharePoint, etc. (Required)
- Ability to manage sensitive and confidential issues (Required)
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.