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.

Manager, Claims

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Manager & Professional
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1912U Requisition #
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Responsible for oversight of Claims Operations including Vendor Management.  Monitor performance and work with other members of the management team to achieve stated goals. Lead and Inspire team through open communication and transparency to ensure high quality and maximize the customer experience.

Responsibilities:
  • Accountable to manage and monitor daily workflow and preparation of daily, weekly, monthly production and inventory reports to ensure business objectives are maintained within State and Federal compliance mandates, including but not limited to: HIPAA, SOX, ERISA, Prompt Pay, and Regulation 64.  
  • Identify and coordinate training and tools to ensure staff members are operating at desired skill and quality levels.
  • Lead and inspire team through open communication. 
  • Develop, evaluate and manage Claims processing and Vendor Operations personnel to ensure high quality and to maximize the customer experience.  
  • Assess individual and team performance on a regular basis and provide developmental feedback.
  • Drive performance metrics for claims quality; implement corrective action plans identified for areas of direct and non-direct controls.  
  • Identify and escalate opportunities for efficiencies intended to reduce rework.  
  • Evaluate business processes and perform high level analysis to leverage opportunities for operational improvements. 
  • Perform initial root-cause analysis for work-flow break-fixes.   
  • Ensure accurate and efficient claims processing while reducing administrative costs and MER.
  • Champion communication and collaboration within areas of oversight and between key areas including but not limited to, Grievance &Appeals, Provider Network Management, Information Technology, external vendors, Vendor Management and Human Resources to effectively develop and implement business solutions.  
  • Assist with the implementation and operational readiness of new technologies and/or software interfaces across multiple platforms in support of corporate and departmental objects to improve efficiencies, accuracy and medical expense ratio (MER) /administrative expense ratio (AER).  
  • Receive research and respond to Operation Quality and regulatory Audits, including providing individual and departmental feedback to claims operation staff and/or vendor operations staff ; handle resolution of system or procedural issues identified by quality reviews and assume leadership role for developmental and implementation of quality initiatives.  
  • Perform other duties as assigned and required by Claims Leadership.
Qualifications:
  • Bachelor’s degree, preferably in Business Management or related
  • 5 – 8 years related work experience required
  • 3 - 5 years of managerial/supervisory experience within a related health care and/or claims environment required
  • Additional years of experience may be used in lieu of educational requirements required
  • 5+ years in claims processing preferred required
  • Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications required
  • Working knowledge of MS Office 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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