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.

Provider Network Claims Support Leader

📁
Director and Equivalent
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191EQ Requisition #
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Oversee Claims for Network Operations including Vendor Management.  Monitor Accounts Receivable Network performance and work with senior leadership to achieve stated quality goals and timeliness of claims processing.  Lead and inspire team through open communication and transparency to ensure high quality and maximize the customer experience.

Responsibilities:
  • Performance Management - Responsible for performance and resource management of AR Review Specialists staff handling all claims inventory, mail correspondence, appeals and special handling.
  • Inventory & Time Management - Responsible for all aspects of aging inventories Claims and Special Handling requests (e.g. Mail Correspondence, Web Portal, Provider Service Calls, etc.). Ensure that all claims are processed accurately and timely in accordance with regulatory and corporate metric and requirements.
  • Planning and Control - Present and report daily, weekly and monthly status and trends on AR Review Specialists production, quality, and claims inventory levels to the Director of Claims. This includes offering recommendations and submitting corrective action plans on improvement and consistency (as needed).
  • Problem Solving - 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.
  • Communication - Champion communication and collaboration within areas of oversight and between key areas including but not limited to, Grievance &Appeals, Operations, Information Technology, external vendors, Vendor Management and Human Resources to effectively develop and implement business solutions.  
  • Improve Efficiencies - 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).  
  • Perform other duties as assigned and required by Claims Leadership.
Qualifications:
  • Bachelor’s degree, preferably in Business Management, Healthcare or related
  • 5-10 years' of managerial/supervisory experience with claims examining operations (e.g. Claims Processing and Adjudication processes) required
  • 5-10 years' experience maintaining large claims inventory, which includes tracking metrics of time service standards, payments of claims and notification of claims received, etc. required
  • 5-10 years' of Healthcare industry experience- hospital, commercial insurance company, or managed care organizations 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- experience manipulating spreadsheets to create standardized reports, utilize vLookups, pivot tables, filter and use formulas 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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