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 Specialist, Pharmacy Systems Operations - Remote

🔍 New York, New York

New

💼: EmblemHealth

📅   : 5 days ago Post Date

Summary of Job

Serve as pharmacy systems coding subject matter expert for Prior Authorization with a focus on medical drug claim processing, review of utilization management, PA processing, and appeals; as well as the following: claims processes and JUDI interoperability with FACETS edits and other connection troubleshooting. Provide technical and subject matter expertise support for implementations and day to day operations of Pharmacy functions and vendor coordination. Support operations for file transfer systems (configuration, deployment, pharmacy management and medical benefits, eligibility). Support operations for system integration, including monitoring files and transitions, fallout, and root cause analyses. Execute non-clinical Appeals from post claim edit process, and consistently maintain queue

Responsibilities

Collaborate in defining, gathering, reviewing, and editing business requirements for system updates, enhancements and migrations for claims projects.
Perform solution analysis review and provide concise direction to ensure that the proposed system solution meets established business protocols, and any mandates and compliance guidelines.
Partner with business analysts, business users and source system experts to produce claim processing output consistent with meeting overall goals.
Review daily, pended medical drug claims for accuracy.
Identify and implement solutions to support automation of claims or resolve with manual intervention.
Collaborate with clinical, formulary, payment integrity and other key players to ensure issues are accurately defined with an appropriate solution.
Submit and track medical claims system configuration requests related to RPC (Reimbursement Policy Committee) decisions, ensuring timely implementation and alignment with approved policy guidelines.
Work with business units to develop test strategies and scenarios from business requirements.
Accurately interpret and translate strategies and scenarios into test plans.
Analyze requirements, test documents and acceptance criteria which will effectively find defects that may exist in claims processing.
Act as a liaison and subject matter expert for day to day medical drug system-related technical questions and/or issues.
Troubleshoot and track all concerns on unpaid claims, working with key stakeholders and respond to all appropriate parties effectively within a timely manner.
Provide written progress report to leadership regarding the status of deliverables, issues, problems and corrective actions taken.
Perform other related tasks as directed or required

Qualifications

Bachelor’s degree required
4 – 6+ years of relevant, professional work experience (Required)
2+ years’ experience in one or more of the following: claims processing, pharmacy/coding, utilization management (Required)
Experience in a healthcare environment (Required)
Proficiency with MS Office - Word, Excel, Access, PowerPoint, Outlook (Required)
Advanced reporting system experience/knowledge - SAS, Oracle, etc. (Preferred)
Track record of successfully managing multiple tasks/projects with competing priority levels/deadlines (Required)
Ability to understand complex technical system requirements and translate into simple business language (Required)
Excellent communication skills - verbal, written, presentation, reporting, interpersonal (Required)
Attention to detail; ability to think critically; ability to identify, quantify, analyze and resolve issues (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.