Claims Review Analyst

EmblemHealth; New York (NY); On-site; USD 49,000 - 83,000; Full time

Job summary

EmblemHealth in New York is seeking a claims analysis specialist to support contract performance management for a large health system. You will review underpaid and overpaid claims from hospital, ancillary, and provider groups according to contractual guidelines.

The role requires 2–3 years of related experience, knowledge of ICD/CPT coding, and proficient MS Office skills. You will identify issues, analyze trends, and propose solutions to reduce errors and delays in processing.

Qualifications

• Bachelor’s degree required; additional experience/specialized training may be considered in lieu of education requirements.
• 2–3 years’ prior related work experience in professional/facility claims or benefits/billing environment required
• Knowledge of claim processing policies and procedures required
• Knowledge of ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
• Proficiency with MS Office applications (word processing, databases/spreadsheets, presentation) required

Responsibilities

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
• Track issues and monitor trends to support their resolution.
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles
• Support departmental goals for cycle time by organizing and tracking claims for review.
• Monitor and provide timely responses for the designated provider group emails and AR files.
• Perform other related tasks as directed or required.

Skills

Analytical skills

Attention to detail

Communication

Problem solving

Time management

Education

Bachelor’s degree

Tools

MS Office

Job description

• Support contract performance management of a large health system.
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
• Identify and analyze single issues and trends to determine root causes.
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
• Monitor system output to ensure proper functioning.
  
  

Summary Of Position

• Support contract performance management of a large health system.
• Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines.
• Identify and analyze single issues and trends to determine root causes.
• Provide recommendations for solutions to minimize errors and delays in systems and/or processes.
• Monitor system output to ensure proper functioning.
  
  

Principal Accountabilities

• Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
• Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
• Track issues and monitor trends to support their resolution.
• Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
• Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles
• Support departmental goals for cycle time by organizing and tracking claims for review.
• Monitor and provide timely responses for the designated provider group emails and AR files.
• Perform other related tasks as directed or required.
  
  

Qualifications

Education, Training, Licenses, Certifications

• Bachelor’s degree required; additional experience/specialized training may be considered in lieu of education requirements
  
  

Relevant Work Experience, Knowledge, Skills, And Abilities

• 2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment required
• Strong knowledge of claim processing policies and procedures required
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required
• Ability to accurately interpret information from contractual and technical perspectives required
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies required
• Strong analytical and problem-solving skills required
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines required
• Ability to effectively absorb and communicate information required
• Strong Interpersonal and teamwork skills required
  
  

Additional Information

• Requisition ID: 1000003278
• Hiring Range: $48,600-$83,160