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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Senior Quality Analyst (Claims)
Summary of Position
- Perform audits and/or provide oversight and guidance to Claim Auditors in completing comprehensive random audits of claims, membership and service inquiry adjustment transactions.
- Determine the root causes of error and recommend appropriate corrective actions to prevent re-occurrence of these errors.
- Support cross-functional Business Transformation initiatives with quantitative transactional analyses and sample audits.
- Support Business Transformation Leaders leading business improvement and integration projects with problem definition and resolution.
Principal Accountabilities
- Perform timely post-payment audits of all claim types to verify the accuracy of the claim payment and processing.
- Perform cycle time analysis and audits of EmblemHealth of root cause and corrective actions
- Perform comprehensive audits of service inquiry adjustment transactions to verify that inquiries from groups, providers and subscribers are resolved accurately and timely.
- Conduct special audits as directed by senior management, including subcontracted operational capabilities.
- Provide problem definition/analysis support to the Business Transformation Leaders and their associated process improvements projects.
- Review and evaluate management responses and corrective action plans related to audit findings; negotiate disputed findings and recommendations with area management.
- Analyze all audit results and identify the root causes of errors.
- Develop appropriate and cost-effective recommendations
- Work with Claims, PFO, PNM, Membership and IT to identify any required system logic modifications related to audit findings.
- Participate in the external audit process, provide instruction to the auditors, research and coordinate responses to specific audit issues or to questions as directed by departmental management.
- Perform comprehensive reviews of new product or system implementations, as requested by management.
- Verify that applicable system data files are updated and claims are accurately adjudicated in accordance with contractual benefit provisions in conjunction with the reviews.
- Regular attendance is an essential function of the job. Perform other duties as assigned or required.
Qualifications
Education, Training, Licenses, Certifications
- Bachelor’s Degree required; Additional year of experience and/or specialized training may be used in lieu of educational requirement
Relevant Work Experience, Knowledge, Skills, and Abilities
3 – 5 years relevant work experience, preferably in auditing and improving operational processes required
- Prior extensive experience in quality and/or root cause analysis required
- Prior knowledge in insurance coding and/or claims experience required
- Knowledge of EmblemHealth’s processes and Facets system preferred
- Strong problem solving and verbal and written communication skills required
- Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access 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, age, creed, citizenship status, 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.