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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Provider Dispute Analyst
🔍 New York, New York
Summary of Position
- Responsible for receiving, researching and resolving provider inquiries received from UMR or internal departments and business partners (i.e., account management, client retention, access to care, G&A, etc.) regarding claim outcomes.
- Perform root cause analysis and take appropriate steps to have corrected, working directly with support areas (Provider Network Management, Provider File Ops, CCT) as needed.
- Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on the provider contract language
- Recommend changes in procedures, desk level procedures (DLPs) and workflow to improve quality and efficiency as needed.
- Ensure impacted claims are adjusted.
Roles and Responsibilities
- Serve as subject matter expert (SME) for resolution of issues related to claims adjudication outcomes for medical and hospital claims for NYCE as requested by UMR.
- Work across multiple groups/departments to ensure that issues are clearly understood and defined, and that they are either resolved or escalated as appropriate.
- Perform root cause analysis and take appropriate actions to ensure root cause is remediated.
- Research and resolve claim issues as requested and make determination of appropriateness of claim adjudication outcome and/or adjustment request.
- Remediation may include configuration updates, recommendation of changes to processing procedures, UMR or Facets workflows, and processing documentation tools.
- Collaborate with EmblemHealth business partners as needed via email or virtual meetings to validate accuracy ofNetworX rate sheets, provider participation status, and provider file impacting the claim(s) adjudication outcome.
- Support NYCE SLA agreements by providing timely turnaround of cases to ensure alignment with specified parameters of completion, timeliness, and accuracy.
- Perform follow up as needed to ensure the issue has been resolved; provide documentation with appropriate level of detail in “speak human” terms so that all information is communicated and understood clearly, including claim adjustment detail(s) and/or explanation for payment correctness to the requestor.
- Perform other related tasks and responsibilities as directed, assigned, or required.
Qualifications
- Bachelor’s degree, preferably in Business Management required
- 3 – 5+ years of relevant, professional work experience required
- 2 – 3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits required
- Experience managing in a BPASS model preferred
- Experience within a health care and/or claims environment required
- Additional years of experience may be used in lieu of educational requirements required
- Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications required
- Strong knowledge of member and provider contracts, procedures and systems required
- Prior proven EmblemHealth experience preferred
- Strong planning, organizational, interpersonal, verbal and written communication skills required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
- Ability to successfully manage multiple tasks with competing priorities and deadlines 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.