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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Manager- Provider Claims Resolution - Hybrid
Summary of Job
Responsible for management of all Provider Claims resolutions; ensure that all claims are handled timely and accurately. Maintain thorough knowledge of all provider contracts and translate language into Emblem terminology, with an understanding of Emblem’s various processing systems including claims and provider systems to evaluate ability to process claims according to contracts. Serve as a subject matter expert in all areas of contract configuration, fee schedules/groupers, and rate reimbursement. Provide recommendations for process improvements; manage process change implementations. Fully comprehend the downstream impact of loaded rates within EmblemHealth’s full claims reimbursement cycle.
Responsibilities
- Oversee a unit of claims experts to review, reconcile and resolve claims inquiries, handling all claims inventory, appeals and special handling: hire, develop, mentor, train staff; clearly communicate expectations; monitor and provide feedback; ensure appropriate levels of staffing; complete performance reviews.
- Manage performance of team for claims quality; implement corrective action plans identified for areas of direct and non-direct controls.
- Responsible for all aspects of aging inventories of Claims and Special Handling requests.
- Ensure that all claims are processed accurately and timely in accordance with regulatory and corporate metrics and requirements; coordinate with multiple departments to review the need for claim adjustments due to contract/provider/system issues.
- Present and report daily, weekly and monthly status and trends on AR Review Specialists production, quality, and claims inventory levels; offer recommendations and submit corrective action plans on improvement and consistency.
- Analyze and trend inventories, performance results, and requests to determine root cause. Evaluate opportunities to improve the handling and routing of claims using workflow system.
- Work in conjunction with other operating units to analyze results and identify areas for process and quality improvement while providing timely feedback to stakeholder functional units.
- Drive process, quality and high-performance culture that ensures timely and accurate adjudication of claims connected to NetworX, TruProvider Linkage and Claim Engines.
- Communicate and collaborate with key/oversight area such as Grievance & Appeals, Provider Network Management, Information Technology, external vendors and Vendor Management to effectively develop and implement business solutions.
- Perform other duties/tasks as directed or required.
Qualifications
- Bachelor’s degree, preferably in a business, healthcare or operations related field, Master’s preferred.
- 5 - 8 years’ relevant work experience (Required)
- 3 - 5 years of experience working in a health care delivery system (Required)
- Detail Oriented; analytical ability; problem-solving skills (Required)
- Strong proficiency in Microsoft Visio, Excel, and Word (Required)
- Proven ability to identify and continuously enhance efficiencies associated with Network operations (Required)
- Ability to develop, use, interpret and apply key business metrics (Required)
- Ability to organize and lead key initiatives (Required)
- Strong written and verbal communication skills; ability to effectively communicate 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.