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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2008U Requisition #
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Support contract performance management of a large health system.  Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.  Identify and analyze single issues and trends to determine root causes.  Provide recommendations for solutions to minimize errors and delays in systems and/or processes.  Monitor system output to ensure proper functioning.

Responsibilities:
  • Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
  • Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
  • Track issues and monitor trends to support their resolution.
  • Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
  • Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
  • Develop and maintain detailed understanding of rates as per assigned contract.
  • Support departmental goals for cycle time by organizing and tracking claims for review.
  • Special projects as needed.
Qualifications:
  • Bachelor’s Degree
  • Additional years of experience and/or training can be used in lieu of educational requirements required
  • 2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment required
  • Strong knowledge of claim processing policies and procedures required
  • Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
  • Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required
  • Ability to accurately interpret information from contractual and technical perspectives required
  • Must be conscientious and detail oriented, recognizing unusual patterns and troubleshooting for operational improvement and efficiencies required
  • Strong analytical and problem-solving skills required
  • Ability to effectively work on multiple projects/tasks with competing priority levels required
  • Ability to effectively absorb and communicate information required
  • Strong Interpersonal and teamwork skills 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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