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.

Director, Claims Operations

Director and Equivalent
190PD Requisition #
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Accountable for multi-site daily department operations (including requires inbound, outbound and interdepartmental workflow activities).  Lead the department and implementation of all processes related to the adjudication of dental, hospital and/or medical claims, correspondence and adjustment work, including processing of all high dollar claims.  Maintain Regulatory regulations, HIPAA and SOX compliant departmental policies, procedures and workflows while adhering to HEDIS and NCQA standards to ensure continued accreditation.  Serve as the key liaison across all departments Enterprise wide and regional locations (Melville, Manhattan, Albany NY and Farmington CT) that impact Claim operations. Lead collaboration with these areas to implement business processes and system enhancements designed to promote auto-adjudication, correct coding initiatives, continuous improvement and reduction in rework.  Key Claims Liaison for transition/vendor initiatives, including development of Statement-of Work, Service Level Agreements, Policy & Procedure and Workflows; facilitate prioritization of system enhancement initiatives relating to the Medical Claim System and coordinate user acceptance testing activities.

  • Operational Performance – Responsible for achieving consistent, high quality performance metrics results via well executed operational fundamentals with an emphasis on accuracy, timeliness and efficiency.  
  • Hold direct reports accountable for individual, team and departmental performance – ensuring the department manages to its established SLA’s for claims inventory, Adjustment inventory and Correspondence inventory.  
  • Drive performance metric claim quality and implements corrective action plans of improvements for identified areas even if not in direct control of the function; ensure operational readiness for new products.
  • Report and analyze daily volumes, AA rate etc. for trends.
  • Accountable for reporting results to leadership and to develop/implement corrective action plans if required.
  • Failure to meet objectives may reduce overall customer satisfaction (i.e. lower CAHPS scores) and expose the enterprise to loss of enrollment or network participation as well as risk of citation and penalties for non-compliance with regulatory agencies; 
  • Leadership – clear communication of accountabilities and priorities to leadership and staff with regular review of progress. Regular review of departmental policies and procedures to ensure alignment of work and desired results. Inspire the team through open communication and delegation of responsibilities and authority.  Lead with emotional intelligence and transparency; develop succession plans for the leadership team; direct the deployment of training and tools to ensure front-line leadership and staff are operating at desired skill levels.  Responsible for creating the vision for the claims unit(s) and driving the teams to realize that vision. 
  • Audits /Compliance – Oversee audits of claims payment and policies, implementing corrective plans of action to address identified areas of non-compliance or error.   Ensure a regular review of departmental policies and procedures so that the Claims Operation team adheres to all New York State and Federal compliance related mandates including but not limited to HIPAA, SOX, ERISA, Prompt Pay, Regulation 64.
  • Process Improvement/Efficiency - critically and continually evaluate core business processes based on rework received through correspondence and adjustment work in an effort to leverage opportunities for operational improvements. Emphasis should be on improving quality, reducing the number of touches per claim and increasing our auto-adjudication rate.   The overall goal is to adjudicate claims accurately and efficiently while reducing administrative costs and MER. 
  • Champion creative innovations that lead to enhanced performance levels with an eye towards achieving higher levels of customer satisfaction while enabling Emblem health to outperform competitors in a competitive market place.  Utilize monthly quality scores to drive refresher training opportunities at either an individual level or from a holistic view.   
  • Ensure that root cause issues are identified and fixed, leveraging the payment integrity unit as well as other avenues.
  • Communication/Collaboration – Responsible to lead the collaboration between key areas including IT, EPMO, Shared Services, Provider Network Management, and customer service in order to effectively develop and implement technical business solutions.  Identify opportunities to centralize common processes within the Claims organization. 
  • Strategic Planning and Budgeting – Accountable for contributing to and meeting the annual budget for their department and executing on any staff resource plans.  Support enterprise-wide projects that will further Emblem Health’s mission and promote high quality performance internally.
  • Bachelor’s degree in Business Management or related equivalent field; Master’s degree preferred
  • 10 years of relevant work experience required
  • Minimum 5 years’ experience in managing high volume claims processing area required
  • Additional years of experience/specialized training may be used in lieu of educational requirements required
  • Proven experience in managing/directing an Operations function, preferably in a healthcare provider environment required
  • Proven ability to develop, mentor, and inspire staff to achieve consistently excellent results required
  • Excellent communication (verbal, written, interpersonal) skills required
  • Knowledge of claims systems and interdependent applications required
  • Ability to travel 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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