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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Senior Provider Operations Specialist - Remote
Summary of Job
Manage the relationship between Cognizant and Provider Network Management. Outreach to providers as needed when discrepancies in Provider Data or required documentation is needed for compliance requirements. Maintain current knowledge of NCQA, state and federal requirements. Maintain communications with provider offices to promote relationships imperative to process. Serve as a subject matter expert and support Provider Ops Specialists. Collaborate cross-functionally to streamline workflows, support audits, and drive process improvement.
Responsibilities
- Partner with the Credentialing Supervisor to monitor daily reports and dashboards.
- Collaborate with leadership to identify areas of improvement and root cause analysis based on internal and external audits.
- Responsible for the development and review of training materials, desktop procedures and policies. Provide feedback on cross-departmental projects and initiatives.
- Accountable to outreach recredentialing non-responders to ensure compliance with recredentialing standards and prevent provider termination.
- Establish and maintain subject matter expertise on Federal, State, and NCQA regulatory and compliance requirements and assist in driving policy and process at an enterprise level (EH, CCI, NJ).
- Take initiative to continuously develop and conceptualize approaches on more efficient ways to perform recredentialing outreach and maintain accurate provider data.
- Work as a liaison between Cognizant Credentialing team and Provider Network Management to address any process issues or provider education needs.
- Analyze recredentialing report data to compare intended outcomes with actual outcomes and evaluate quality controls to assess effectiveness in identifying errors in the process.
- Proactively identify opportunities for improvement, systematic enhancements, and standardization of departmental practices across the enterprise of Credentialing and Recredentialing.
- Communicate results to Manager and Provider Operations Tower Leaders.
- Assist Provider File Operations when data discrepancies are found to outreach providers as necessary and ensure accurate provider directories.
- Perform all other related duties as directed or required.
Qualifications
- BS or BA degree.
- Certification in Quality Mgmt. / Organizational Excellence; or achieving and maintaining certification within 1 year of assuming this role as a condition of continuing employment
- 4 – 6+ years of relevant work experience, including 2+ years in auditing and assessment activities (Required)
- Additional related experience/specialized training may be considered in lieu of educational requirements (Required)
- Work experience and process and regulatory expertise in Credentialing – subject matter expert in function (Required)
- Energy, drive and passion for End-to-End excellence and customer experience improvement (Required)
- Excellent collaboration skills and the ability to influence management decisions (Required)
- Strong auditing skills that can be applied across all types of business problems (Required)
- Strong communication skills - verbal, written, presentation, interpersonal with all types/levels of audiences (Required)
- Proficient in MS Office - Word, Excel, PowerPoint, Outlook (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.