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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Summary of Position

• Responsible for receiving, researching and resolving inquiries and requests from internal EmblemHealth departments and business partners (i.e., account management, provider network management, provider file operations, client retention, access to care, care café, membership, COB, Contact Center, G&A, etc.) regarding claim outcomes.
   
• Perform root cause analysis and take appropriate steps to have corrected, working directly with support areas (EmblemHealth & CTS) as needed. 
   
• Recommend changes in procedures, desk level procedures (DLPs) and workflow to improve quality and efficiency as needed. 
   
• Ensure impacted claims are adjusted. 
   
• Oversight and quality review of CTS performance.
   
• Provide response to requestor using “speak human” terminology.

Roles and Responsibilities

• Serve as claim processing subject matter expert (SME) for resolution of issues related to claims processing and adjudication outcomes for medical, hospital, dental claims for all EmblemHealth lines of business as requested by EmblemHealth business partners or CTS business partners. 
   
• Research and resolve claim issues as requested and make determination of appropriateness of claim adjudication outcome and/or adjustment request. 
   
• Provide oversight and quality review of CTS performance of the claim adjustments required.
   
• Perform root cause analysis and take appropriate actions to ensure root cause is remediated. 
   
• In addition to requesting configuration updates, remediation may include recommendation of changes to processing procedures, Facets workflow and desk level procedures (DLPs).
   
• Collaborate with EmblemHealth and CTS business partners as needed to validate accuracy of benefit configuration, NetworX rate sheets, provider participation status, provider file and membership file, including COB flags impacting the claim(s) adjudication outcome. 
   
• Manage high priority/high visibility projects to completion including manual or mass recycles and adjustments.
   
• Ensure issue is closed, providing documentation with appropriate level of detail in “speak human”, including claim adjustment detail or explanation for payment correctness to the requestor
   
• Perform other related projects and duties as assigned

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.

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.

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. 

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.