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.

Vendor Operations Performance Analyst (Claims)

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Manager & Professional
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190SX Requisition #
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Continuously and proactively assess and monitor vendor operations performance to achieve contractual targets on a daily basis.  Frequently interface with Vendor Operations Tower Leaders to continuously identify and communicate opportunities for improvement with claims, customer service, benefit set-up, enrollment and billing, provider set-up and medical and pharmacy core processes.  Identify areas of improvements in operational areas, provide appropriate action plans, develop and implement Vendor Operations performance analysis programs and metrics to improve operational efficiency.  Personally own the EmblemHealth brand and customer experience by continuously identifying opportunities for improvement and variation trends via proactive assessment.

Responsibilities:
  • Assess and monitor performance of vendors for each core process to meet contractual requirements and align with EmblemHealth customer experience objectives. Conduct reviews, transactional audits, and compliance and operational procedure reviews.
  • Work with various business partners to define, design and develop analytic solutions to improve optimization and identify and mitigate risks, applying timely, accurate and consistent understanding of risk across the organization to predict and gauge operational risks.
  • Analyze performance data to compare intended outcomes with actual outcomes and evaluate quality controls to assess effectiveness in identifying errors in systems and processes and communicate results to Vendor Operations management via reports and presentations.
  • Maintain meticulous audit and other assessment records to baseline historical performance and track and trend over time. Document special variation events that impact performance as well as corrective action taken to address issue.
  • Communicate and collaborate with other Vendor Operations Management stakeholders as needed to support overall EmblemHealth quality and customer experience objectives. Feed opportunities to your respective Vendor Operations Tower Leaders on a real time basis to ensure proper and timely escalation to accountable parties.
  • Support Vendor Operations Tower Leads as need to conduct ad-hoc assessments and assignments.
Qualifications:
  • BS or BA degree
  • Additional years of related experience may be used in lieu of Degree
  • Achieve Quality Management / Organization Excellence certification or equivalent certification within 1 year of assuming this role
  • 3+  years of relevant experience in auditing and assessment activities required
  • Pharmacy Experience preferred
  • Process expertise for Tower required
  • Excellent collaboration skills and the ability to influence management decisions required
  • Strong auditing skills that be applied across all types of business problems required
  • Working oral and written communication skills required
  • Work experience for functional Tower – subject matter expert in function required

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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