Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Claims Quality Oversight Analyst
🔍 New York, New York
Summary of Position
- To oversee the performance of vendors who are delegated for the claims processing function to ensure delegates meet and are aligned with EH standards.
- Accountable to perform quality assurance oversight of delegated vendors and administer EH Delegated Vendor Oversight Committee (DVOC) annual audits of the delegated arrangements.
Job Responsibilities
- Administer audits of the delegate claims processing function:
- Request supporting documentation for randomly selected samples of delegate processed claims.
- Work with the RM to ensure that all delegate-provided information is complete prior to commencement of audit.
- Review all documentation and populate DVOC audit tool with claims detail for all selected samples.
- Review delegate’s Claims policies & procedures and score the DVOC audit tool for completeness.
- Conduct exit conference with delegates to discuss audit findings.
- Share findings with delegate and review disputes.
- Prepare all applicable audit memos for presentation to the DVOC (audit memo, CAP and CAP updates memos)
- Administer CAPs and monitor to ensure that the corrective plans are completed and tested within timeline.
- Meet with delegates to discuss areas of concern in the timely resolution of identified issues.
- Work closely with RMs to obtain supporting documentation to support delegate’s confirmation of resolution.
- Analyze monthly KPI reporting packages received and prepare analysis report to share with delegate for response.
- Ensure completeness and adherence to claims processing TATs and all other designated claims metrics.
- Review for trends adversely impacting claims processing quality and highlight in written analysis.
- Participate in monthly Administrative Operating Committee meetings with delegates to discuss areas of concern within the claims’ metrics and status updates on implementation of open corrective actions.
Qualifications
- Bachelor’s Degree; additional years of experience/specialized training may be considered in lieu of educational requirements required
- 2 – 3 years’ experience in claims auditing required
- 1+ years’ experience working in BPASS model preferred
- Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations required
- Excellent organizational and time management skills required
- Extensive knowledge of professional and facility claims processing systems required
- Strong analytical and deductive evaluation skills to anticipate and resolve potential claim systems discrepancies and the ability to propose effective solutions required
- Proficiency with MS Office applications (Word, Excel, Access, etc.) required
- Effective communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences required
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.