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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Sr. Claims Analyst
🔍 New York, New York
Summary of Position
- Perform high dollar claim audits and provide oversight and guidance to claim analysts.
- Determine the root cause of errors and recommend appropriate corrective actions to prevent re-occurrence of these errors.
- Support business initiatives with quantitative transactional analysis and sample audits.
- Support business leaders with business improvement and integration projects.
Roles & Responsibilities
- Perform timely pre-payment audits of high dollar claims to verify the accuracy of claim payment and processing.
- Perform cycle time analysis to determine root cause and corrective actions.
- Perform comprehensive audits of adjustment transactions to verify that inquiries from groups, providers and members are resolved accurately and timely.
- Conduct special audits as directed by leadership.
- Provide problem definition/analysis support to the business leaders and their associated process improvements projects.
- Review and evaluate management responses and corrective action plans related to audit error findings.
- Work with leadership on disputed audit findings and make recommendations for corrective actions.
- Develop appropriate and cost-effective recommendations by partnering with Claims, Provider File Ops, Provider Network Mgmt., Utilization Mgmt. and IT to identify any required system logic modifications related to audit findings.
- Perform comprehensive reviews of new product or system implementations as requested by leadership.
- Participate in the external audit process by responding to specific audit issues or questions as directed.
- Make recommendations and modifications to the audit program desk level procedures (DLP’s) based on changing business environment.
- Perform other duties as assigned, directed, or required.
Qualifications
- Bachelor’s degree
- 3 – 5+ years relevant work experience, preferably in auditing and improving operational processes
- Additional years of experience and/or specialized training may be considered in lieu of educational requirements
- Extensive experience in quality and/or root cause analysis
- Working knowledge of insurance coding and/or claims experience
- Knowledge of Emblem Health’s processes and FACETS system
- Detail oriented; strong problem identifying and solving skills
- Strong communication skills (verbal, written, presentation, interpersonal)
- Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access
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.