Director, Risk Contracting & Management

📁
Director and Equivalent
💼
EmblemHealth
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  • Responsible for oversight and management of the St. Barnabas, Montefiore, HealthCare Partners (HCP) and other assigned global risk contracts with EmblemHealth (EH) and is the accountable Relationship Director for these delegates enterprise-wide.
  • Serves as liaison for all internal functions impacted by these delegates, including Network, Claims, Customer Service, Sales and Account Management. Manages a support team.

Responsibilities:

  • Develops and manages a comprehensive process to monitor and enforce EmblemHealth’s oversight of the St. Barnabas, Montefiore, and HealthCare Partners (HCP) global risk contracts, including establishing procedures and workflows with internal Subject Matter Experts to ensure compliance with all contract terms, regulations, and financial requirements. Establishes and manages Performance Guarantees including necessary reporting.
  • Ensures that the delegates follow EH policies and procedures pertaining to interactions with members and providers; ensures that the member and provider experience with the delegate facilities mirrors that of EH; is the escalation point for all delegate related member and provider issues.
  • Establishes and manages oversight parameters for delegated functions, including Claims Payment, Customer Service, Credentialing, Utilization Management and Appeals. Leads and manages Administrative Operating Committee and Joint Operating Committees with the delegates and internal constituents.
  • Financial management of delegate contracts, including review of monthly capitation details, management of wire process, review and response to capitation error reports. Manages chargebacks and closes prior periods through contract amendments. Works closely with finance and actuary to set accruals, monitor reserves and administer contract incentives.
  • Identifies and executes on opportunities for contractual and operational improvements.
  • Develops and manages Transitional Plan from delegate to EH should agreements be discontinued for any reason.
  • If/when the company decides to explore new Risk Contract(s), the incumbent shall be one of the key players not only in the negotiations but also in the implementation of any future contract(s).

Requirements:

  • BA required; Master’s degree preferred (MBA, MPH, MA)
  • 10+ years relevant experience including provider contracting, risk contracting and risk management or other relevant (R)
  • Ability to multi-task and manage multiple priorities (R)
  • Strong problem solving skills (R)
  • Strong interpersonal skills and ability to influence (R)
  • Familiarity with provider community and health care marketplace trends and superior knowledge of provider risk (R)

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