Medical Claims Review Analyst (remote)

EmblemHealth; New York (NY); Remote; USD 45,000 - 77,000; Full time

Job summary

An established industry player is seeking a detail-oriented Claims Analyst to support contract performance management in the healthcare sector. This role involves reviewing and analyzing claims, identifying trends, and providing solutions to enhance operational efficiency. The ideal candidate will possess strong analytical skills and a solid understanding of claims processing policies. Join a forward-thinking company that values diversity and inclusion while making a meaningful impact on the health care experience. If you are passionate about improving processes and ensuring quality care, this opportunity is perfect for you.

Benefits

Competitive health benefits

Retirement benefits

Incentive pay plans

Qualifications

• 2-3 years of experience in claims or billing environment.
• Strong knowledge of claim processing policies and medical terminology.

Responsibilities

• Evaluate disputed claims and maintain detailed information on disputes.
• Identify claims problems and document root cause analysis.

Skills

Analytical Skills

Problem-Solving Skills

Attention to Detail

Interpersonal Skills

Communication Skills

Education

Bachelor’s Degree

Tools

MS Office

Job description

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continuous improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

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.

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.

Qualifications:

• Bachelor’s Degree
• 2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment (Required)
• Additional experience/specialized training may be considered in lieu of educational requirements (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: 1000002234
• Hiring Range: $45,000-$77,000

Security Disclosure

If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online.

Pay Disclosure

A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.