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 Review Analyst

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Manager & Professional
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2005Y Requisition #
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Provides Operational and Claims System analysis. The incumbent analyst will be responsible for reviewing and resolving denied, pended and corrected claims. Analyzes claim resubmissions to determine areas for provider education or system re-configuration. Serve as the primary point of contact for claim issues raised by Providers and internal departments. Provides feedback on department workflows and identifies opportunities for redesign. Performs claims testing to ensure that systems are designed efficiently based on the Plan's benefit structure. Reflects a full understanding of Emblem business practices, provider networks, reimbursement methodologies, and changes in NYS reimbursement methodologies.

Responsibilities:
  • Monitors and resolves high volume of claims for all lines of business, as well as claims for performance guarantee groups and high dollar claims, to minimize late payment interest penalties and ensure compliance with established guidelines
  • Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
  • Responsible for conducting root cause analysis and working with staff in other business areas to assist with the resolution of complex Provider claim issues.
  • Analyze data issues and work with development teams for problem resolutions. Identify problematic areas and conduct research to determine the best course of action to correct the data, identify, analyze and interpret trends and patterns in complex datasets.
  • Performs other duties as assigned or required.
Qualifications:
  • Bachelor’s Degree in Information Management, Healthcare Informatics, Computer Science, Business Administration, Statistics
  • Minimum of 3-5 years' experience contributing to the analysis of large medical insurance claims databases required
  • Extensive knowledge in Claims Systems Processes required
  • Proficient in MS Excel and SQL Server for testing and validating data required
  • Proficient in writing Microsoft Structured Query Language (SQL) queries required
  • Strong analytical and quantitative skills required
  • Proficient knowledge of contracts, benefits and pricing modules required
  • Advanced understanding of medical coding systems (CPT/HCPCS, ICD-9 and 10, DRG, etc. required
  • Extensive knowledge in formalizing testing strategy and detailed auditing principles and techniques required
  • Ability to manage full cycle analytical/reporting solution from requirements gathering to data modeling and report authoring required
  • Understanding of relational database concepts - Familiarity with healthcare reimbursement systems and methodologies
  • Lean Six Sigma or Green Belt certification a plus; preferred

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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