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.
Sr. Claims Analyst - (3 positions available)
Summary of Job
Ensure prompt, efficient, accurate and timely claims adjudication of high dollar claims in accordance with the current policy benefits, limitations or exclusions. Provide resolution of provider inquiries and collaborate with internal departments. Provide feedback or suggestions to enhance current processes and/or systems.
Responsibilities:
- Research and adjudicate high dollar claims, in accordance with the current policy benefits, limitations, or exclusions through a claim processing work queue.
- Perform claim adjustments of high dollar claims and handles reconciliations of questionable claims.
- Provide feedback or suggestion to enhance current processes and/or systems.
- Meet or exceed all required claim productivity, quality and timeliness standards.
- Promote delivery of highest quality of services through research and review of issues, continual evaluation and correction of root causes behind service problems.
- Propose workflow changes to correct and enhance claim processes.
- Work with internal departments including Sales, Legal, Provider Network Management, Provider File Operations, Customer Service, and Utilization Management to gather information needed to resolve high dollar claim issues.
- Promote delivery of highest quality of services through research and review of issues, continual evaluation, and correction of root causes behind service problems.
- Perform other related projects and duties as assigned, directed, or required.
Qualifications:
- Bachelor’s Degree
- 3 – 5+ years’ claims processing experience, preferably working in an HMO, managed care or self-insured environment (Required)
- Additional experience/specialized training/certification may be considered in lieu of degree requirements (Required)
- Knowledge of claims processing rules and coding experience with DRG, ICD10 and CPT4 (Required)
- FACETS system knowledge (Preferred)
- Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) (Required)
- Knowledge of HIPAA guidelines (Required)
- Demonstrated leadership abilities and the ability to handle multiple simultaneous priorities and meet deadlines (Required)
- Strong communications skills (verbal, written, presentation, interpersonal) (Required)
- Excellent attention to detail, judgment, analytical, and problem-solving skills (Required)
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
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/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, 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.