Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Claims Inventory Manager

📁
Manager & Professional
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ConnectiCare
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Responsible for the oversight of the claims inventory management by our external vendor (CTS): develop, implement and manage the claims oversight department, to monitor and evaluate all aspects of claim inventory (volumes, age, quality, outcomes) for enterprise (HMO, CCI & PPO, Medical, Dental and Hospital) to ensure corporate objectives & targets are met. Ensure regulatory requirements and reporting needs are met to avoid penalties or sanctions. Analyze and report claims information including relevant health care trends and high cost claims by segment to business partners to ensure proper financial accruals. Report identified issues and opportunities immediately to vendor operations business partners via daily huddle; drive remediation as needed; communicate observations and findings to leadership, as well as other business partners. Ensure business partners are equipped with information necessary to respond to customer inquiries.  

Responsibilities:

  • Provide oversight of vendor and business partners’ performance related to the timely and proper disposition of claims: ensure first pass claims, claim adjustments and correspondence inventories are in compliance with policies, metrics and vendor SLAs.
  • Validate vendor adherence to State and Federal regulation and mandates (i.e., prompt pay). 
  • Drive vendor and other business partners to ensure any specific client performance guarantees are being met (i.e. NYS Dental guarantee, FED VIP, FEHB Inquiry timeliness, etc.).
  • Provide timely and direct feedback to vendor business partners on performance outcomes; actively question claims not in compliance with processing and timeliness standards. 
  • Actively participate and engage in corporate projects, PPM meetings, meetings and training regarding new mandates or changes to existing regulations. 
  • Act as subject matter expert (SME) as requested on projects.
  • Ensure any changes needed to claim processing workflows and/or Desk Level Procedures are implemented timely.
  • Track and evaluate vendor partners operational readiness for new project implementations, key program initiatives, regulatory changes and mandates.
  • Review, verify and approve training timeline, desk level procedures and workflows for accuracy, completeness and compliance to ensure claims processing readiness.
  • Champion communication and collaboration within areas of oversight and between internal stakeholders and key business partners to support overall EmblemHealth quality and customer service objectives; Implement corrective action plans for outcomes that are non-complaint more than 2 months in a row. 
  • Monitor and evaluate claim adjustment reason trends and identify strategies intended to reduce rework. 
  • Implement Process improvements through active engagement with business partners (EH & vendor) within operations as well as upstream and downstream departments. 
  • Collaborate with business partners on opportunities to improve processing efficiency and quality. 
  • Identify issues due to production breaks causing delays in timely adjudication and collaborate with the internal claim support team on root-cause analysis and fixes.
  • Perform other duties as assigned and required by Claims Oversight Leadership.

Qualifications:

  • Bachelor’s degree in Business Management
  • 4 - 6 years related work experience required
  • 3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits required
  • 1-3 years’ experience managing in a BPASS model preferred
  • Additional years of experience may be considered in lieu of educational requirements required
  • Strong knowledge of claims processing procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications required
  • EmblemHealth experience preferred
  • Facets experience preferred
  • Strong planning, organizational, interpersonal, verbal and written communication skills required
  • Must be PC literate and possess a strong understanding of Microsoft applications required
  • Ability to handle multiple priorities and meet deadlines required

EEOC Statement

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.

Sponsorship Statement

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.

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