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.

Senior Claims Adjuster (Albany)

Bargaining Unit
190WV Requisition #
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Description of Duties:

  • Evaluate medical claims that suspend within the Medical Claims System utilizing EmblemHealth’s PPO proprietary conventional coding structure. Apply all PPO Coding & Pend desktop procedures during edit resolution.
  • Correct claims as required for settlement utilizing established policies and procedures.

  • Utilizing Claims Operation’s C-More Adjudication Guidelines portal, reference QA memorandums, training guidelines, departmental memos, PRG’s, etc. and apply business rules to claims as instructed for adjudication.

  • As necessary, manually price claims utilizing the appropriate rate files while considering the provider’s network and the beneficiary’s insurance policy. The ability to interpret contract files and apply to adjudication of pended claims.

  • As needed, access PPO’s PC Helper applications such as CWI-Viewer Application, Anesthesia Calculator, PC History Look-Up and any other helper application developed by EmblemHealth to support claims processing.

  • Perform related duties as assigned.


  • Knowledge of medical terminology preferred

  • Minimum of (1) year prior claim processing experience preferred

  • Ability to compose concise, clear letters

  • Must pass an online Data Entry Assessment

  • Must pass a job-related written Claims Simulation

  • High school diploma or GED required

Test Subjects:

  • Claims Simulation & Data Entry Assessments

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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