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.