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 cafe, 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
Qualifications:
- Bachelor's degree, preferably in Business Management.
- 3 - 5+ years of relevant, professional work experience, including 3 years of claims processing.
- 3+ years of managerial/supervisory experience within a related health care and/or claims environment.
- Working knowledge of medical terminology, provider reimbursement, ICD-10, HCPCS and CPT-4 coding, coordination of benefits.
- 1 - 3+ years' experience managing in a BPASS model.
- Additional years of experience may be considered in lieu of educational requirements.
- Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations and Coordination of Benefits applications.
- Strong knowledge of member and provider contracts, procedures and systems.
- Prior proven EmblemHealth experience.
- Strong planning, organizing and prioritizing skills; meticulous attention to detail.
- Strong communication skills (verbal, written, presentation, interpersonal) with all types and levels of audiences.
- Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.).
- Ability to handle multiple priorities and meet deadlines.
Additional Information
- Requisition ID: 1000003099
- Hiring Range: $56,160-$99,360
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EmblemHealth
Apr 25, 2026