Responsible for management of all network operations.E nsure streamlined and uniform processes across vendor network functions that will minimize risk and maximize efficiencies and ROI's. Direct and manage the following aspects of Network Operations: Continuous Operational Improvement; Claims Resolution.
Consolidate and centralize all operational areas under Network Strategy; develop and implement uniform processes designed to streamline operational duties.
Develop and execute on operational strategy that continuously evaluates quality of operations, and course corrects when needed.
Cultivate cross-functional relationships and determine and drive cross functional processes and teams with an end to end focus.
Create, maintain and oversee a unit of claims experts to review, reconcile and resolve claims inquiries.
Perform comprehensive claims-data analysis and interpretation to seek insights into network performance
Drive process, quality and high performance culture that ensures timely and accurate adjudication of claims.
Cultivate relationship with external vendors (Cognizant) and coordinate internal and external operations and deliverables to ensure timely and accurate adjudication of claims.
Manage team to develop and drive workflows and business processes to ensure efficient interaction with Network Development, Analytics, and other areas, to ensure accurate configuration and maintenance of contracts to systems.
Drive audits and continuous improvement in the area of contract configuration management.
Responsible for developing and maintaining the Payment Integrity center of excellence across the enterprise and ensuring proper reconciliation of payments.
Oversee development and deployment of preferred providers list for Fee for Service Provider Network.
Conduct root cause analyses and drive continuous improvement in payment integrity, ensuring proper and timely payment cycles and the prompt recovery of overpayments or otherwise incorrect payments.
Lead the enterprise payment integrity function responsible for the end to end identification and resolution of coding and processing issues across the plan.
Bachelor's degree, preferably in a business, healthcare, or operations related field, Master's strongly preferred
10 12 years' relevant work experience, in positions of increasing impact, scope, complexity, and responsibility required
5-8 years of experience working in the health care delivery system required
Evidence of critical thinking and creative problem-solving skills required
Strong proficiency in Microsoft Visio, Excel, and Word required
Proven ability to identify and continuously enhance efficiencies associated with network operations required
Ability to develop, use, interpret and apply key business metrics required
Ability to organize and lead key initiatives required
Strong written and verbal communication skills; ability to effectively communicate with all types/levels of audiences required
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.