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

Maintain the department’s quality initiatives along with assisting in the development, implementation and maintenance of the department’s quality assurance program. Identify and develop the methodologies for measuring the quality standards, track the department’s quality outcomes and provide a standardized report of the results. Collaborate with various teams, conduct audits, and compile reports on quality metrics. Ensure compliance with regulations and company policies, identify trends and areas for improvement, and contribute to process improvements.

Principal Accountabilities

• Perform quality audits and file reviews in a professional and confidential manner which includes consistent development, retention and application of EH benefits, contracts and departmental procedures. 
• Analyze patterns and trends to identify systemic issues within the grievance and appeal process.  
• Recommend changes to processes, training programs, and documentation to enhance quality and compliance.  
• Maintain accurate daily logs of the files audited/prepares written reports including recommendations for improvement.  
• Prepare for and participate in both internal and external audits related to grievances and appeals.  
• Track and report on key metrics related to grievance and appeal handling to drive improvement efforts.  
• Maintain knowledge of relevant regulations, policies, and best practices.  
• Perform other activities as directed, assigned, or required.

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.