Summary of Position
- Responsible for receiving, researching and resolving provider inquiries received from UMR or internal departments and business partners (i.e., account management, client retention, access to care, G&A, etc.) regarding claim outcomes.
- Perform root cause analysis and take appropriate steps to have corrected, working directly with support areas (Provider Network Management, Provider File Ops, CCT) as needed.
- Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on the provider contract language
- Recommend changes in procedures, desk level procedures (DLPs) and workflow to improve quality and efficiency as needed.
- Ensure impacted claims are adjusted.
Roles and Responsibilities
- Serve as subject matter expert (SME) for resolution of issues related to claims adjudication outcomes for medical and hospital claims for NYCE as requested by UMR.
- Work across multiple groups/departments to ensure that issues are clearly understood and defined, and that they are either resolved or escalated as appropriate.
- Perform root cause analysis and take appropriate actions to ensure root cause is remediated.
- Research and resolve claim issues as requested and make determination of appropriateness of claim adjudication outcome and/or adjustment request.
- Remediation may include configuration updates, recommendation of changes to processing procedures, UMR or Facets workflows, and processing documentation tools.
- Collaborate with EmblemHealth business partners as needed via email or virtual meetings to validate accuracy ofNetworX rate sheets, provider participation status, and provider file impacting the claim(s) adjudication outcome.
- Support NYCE SLA agreements by providing timely turnaround of cases to ensure alignment with specified parameters of completion, timeliness, and accuracy.
- Perform follow up as needed to ensure the issue has been resolved; provide documentation with appropriate level of detail in "speak human" terms so that all information is communicated and understood clearly, including claim adjustment detail(s) and/or explanation for payment correctness to the requestor.
- Perform other related tasks and responsibilities as directed, assigned, or required.
Qualifications
- Bachelor's degree, preferably in Business Management required
- 3 - 5+ years of relevant, professional work experience required
- 2 - 3+ years in claims processing with working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits required
- Experience managing in a BPASS model preferred
- Experience within a health care and/or claims environment required
- Additional years of experience may be used in lieu of educational requirements required
- Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications required
- Strong knowledge of member and provider contracts, procedures and systems required
- Prior proven EmblemHealth experience preferred
- Strong planning, organizational, interpersonal, verbal and written communication skills required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
- Ability to successfully manage multiple tasks with competing priorities and deadlines required
Additional Information
- Requisition ID: 1000002874
- Hiring Range: $56,160-$99,360
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EmblemHealth
Dec 30, 2025