Provider Relationship Manager

Summary of Job

Accountable for oversight and management of specific provider contracts in Provider Network Management. Lead day to day operations for all activities related to contracts, contract optimization, implementation of new programs and business ownership of all EPMO and IT projects associated with contracts. Foster strong relationships across EmblemHealth to advance the strategic goals of the organization. Provide regular check-ins with providers and their offices to ensure needs are met. Manage follow-up on outstanding issues and communicate back to provider/offices and EmblemHealth leadership. Exercise good judgement to determine appropriate escalation of issues, anticipating provider needs. Advise leadership teams on emerging trends and issues. Partner with leadership to ensure organizational excellence. Advise/implement departmental policies and protocols to enhance efficiency and effectiveness of workflows.

Responsibilities

* Lead meetings with key subject matter experts (e.g., quality, risk adjustment, pharmacy and medical management) and delegate to implement new workflows, reporting requirements, regulatory changes, and new products
* Lead joint quarterly and monthly meetings to review progress and performance opportunities with leadership.
* Improve the provider experience, in coordination with providers and with the plan through focused education and training, performance reporting, effective communication of new products, benefits, policies or initiatives, and resolution of provider issues across the business as the primary contact for the account.
* Manage relationships between Providers and Plan.
* Identify and recommend system enhancements and process improvements resulting in savings and associated efficiencies.
* Drive provider performance and engagement through delivery of routine performance scorecards, reports, and population health data (e.g., attributed membership, physician rosters, and utilization).
* Responsible for updating trend reporting/dashboards/issue trackers.
* Create strategies to improve key performance indicators; analyze performance data and identify opportunities and performance drivers.
* Act as primary subject matter expert for each contract.
* Work cross organizationally to ensure successful implementation of provider performance programs and agreements.
* Assure provider contractual relationships and obligations are maintained in compliance with regulatory requirements and EmblemHealth policies and procedures.
* Conduct annual contract reviews and amendments for assigned accounts as required to maintain current and accurate
measures and benchmarks and targets in accordance with NYSDOH, CMS, NCQA, and other regulatory bodies.
* May train and guide staff in creating impactful relationship with provider partners.
* Monitor projects to ensure timely delivery to leadership.
* Work as lead for audits i.e. annual audit, CMS, RADV, Article 44, HEDIA/QARR etc.