Provider Relations Field Representative - EmblemHealth : Job Details

EmblemHealth is one of the nations largest not for profit health insurers, serving members across New Yorks 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, .

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Highly visible, external-facing, field-based role, serving as the primary contact and resource for fee-for-service or value-based providers in assigned territory, with focus on government programs (Medicaid, HARP, Essential, CHP, Medicare). Under minimal direction, works directly with providers to maintain highly satisfying and functioning relationships, engaging with medical office staff, senior leaders, and physicians. Demonstrated subject matter expertise in organizational processes, policies, programs, and provider-facing tools enabling on-the-spot training and education as needed, including onboarding, management of the business relationship and performance, and issue resolution. Develop relationships that drive growth efforts proactively. Increase provider effectiveness through promotion of organizational quality, risk adjustment (condition coding accuracy), administrative cost effectiveness, and provider/member satisfaction initiatives.

Responsibilities

• Conduct a minimum of 10 on-site visits per week with designated high-touch providers to assist with provider issues, education materials, communication of EmblemHealth policies and procedures, contractual obligations, and organizational strategic initiatives.
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, quality resources, and member resources.
• Meet regularly with assigned providers to conduct training and education, such as required annual trainings, systems training, and electronic solutions (EDI, EFT, EMR, Provider Portal, Tableau reports/dashboards).
• Onboard new providers, including in-person sessions or hosting orientation webinars to educate providers on location and content of all provider-facing materials (Orientation, Provider Manual, Newsletter, Program Updates, etc.).
• Coordinate with various functions within the organization (e.g., claims, operations, enrollment, customer service, medical management, vendor management) to ensure appropriate and prompt handling/resolution of provider issues, inquiries and complaints, while balancing provider needs with organizational priorities.
• Take initiative in preventing and resolving issues between the provider and the Plan whenever possible, and independently troubleshoot problems and drive resolution.
• Initiate, coordinate and participate in problem-solving meetings between the provider and internal stakeholders as necessary.
• Support achievement of organizational strategic goals, including organic growth, performance (quality, coding accuracy, efficiency), and satisfaction.
• Deliver actionable data to providers on value-add opportunities and incentive programs.
• Support network development initiatives, including roll-out of new benefit plans, network sculpting and expansions.
• Ensure regulatory and provider network compliance requirements are met for assigned providers.

Qualifications

• Bachelors Degree, preferably in a healthcare related field, Public Administration, Business Administration, or Management.
• 4 6+ years of relevant, professional work experience (Required)
• 3+ years experience in healthcare provider relations, sales, contracting or plan or provider operations, or related in Medicare and Medicaid healthcare setting, ideally with physicians, groups, FQHCs (Required)
• Excellent organizational, project management, and relationship management skills (Required)
• Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required)
• Proficiency with MS Office - Word, Excel, PowerPoint, Teams, Outlook, etc. (Required)
• Understanding of the clinical, economic, and quality components of healthcare (Required)
• Live in assigned territory (Preferred)

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.

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 doesnt 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.

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, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

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.