Contract Specialist

📁
Operations
💼
EmblemHealth
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Load all Professional, Facility, and Ancillary contracts across all EmblemHealth lines of business in a timely and accurate manner.  

Provide subject matter expertise in all areas of contract configuration, fee schedules/groupers, and rate reimbursement.

Collaborate on workflows and business processes to ensure efficient interaction with Network Development, Analytics, and other business areas to facilitate accurate translation and maintenance of contractual agreements into Network.   

Develop expertise in the downstream impact of loaded rates within EmblemHealth’s full claims reimbursement cycle.  

Responsibilities:

  • Participate in all aspects of provider, facility, and ancillary rate configurations in Network within set deadlines, while ensuring full accuracy of contract loads. 
  • Collaborate with Network Management and Analytics to ensure proper capture of negotiated and modeled contractual agreements.
  • Identify and correct rate load problems.
  • Assist with the contract configuration, fee schedule / grouper, and rate reimbursement matters.
  • Analyze negotiated contracts to determine Network interaction with the core systems ensuring that reimbursement is in line with negotiated intent. 
  • In coordination with Network Management, update all evergreen contracts in a timely manner.
  • Recommend contract language changes to be in line with system reimbursement capabilities.
  • Coordinate rate testing with BTS.

Requirements:

  • B. S. degree in Business Operations, Information Systems or equivalent required; Master’s Degree a plus; equivalent experience and specialized certifications/trainings may be considered in lieu of the education requirement
  • Minimum 2-3 years of relevant experience required, preferably in a health care environment
  • Strong familiarity with claims systems and interdependent applications required
  • Experience in provider, facility, and ancillary contract files set-ups, maintenance, testing and auditing functions required
  • Experience in establishing and accomplishing business strategies to successfully translate contractual language into system reimbursement specifications required
  • Excellent knowledge of medical terminology, Fee Schedules, and ICD/CPT/HCPCS coding required
  • Understanding of Government reimbursement methodologies required
  • Analytic, problem solver, excellent organizational and technical skills and attention to detail are required required

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