Senior Claims Project Specialist (Facets Required)

EmblemHealth; New York (NY); On-site; USD 68,000 - 119,000; Full time

Job summary

EmblemHealth in New York seeks an experienced Claims Project Manager to oversee projects ensuring cost, efficacy, and timeliness. You will collaborate with management across functions and act as the Claims SME with internal and external partners.

The role emphasizes leading cross-functional teams, analyzing claims issues, and implementing process improvements to enhance efficiency while ensuring compliance with healthcare regulations.

Qualifications

• Bachelor's degree required; advanced training or certifications may compensate for education gaps.
• PMI or Six Sigma certification preferred.
• 4–6+ years' experience with claims, claims support, vendor oversight, analytics and/or UAT management required.
• Health plan industry experience required.
• Proven track record of successfully managing medium to large projects.
• Experience in staff and process management with increasing responsibilities.
• Experience using metrics and analytics to define and verify outcomes relative to SLAs.
• Health plan functional, operational, analytics and/or UAT domain expertise required.
• Strong communication skills (verbal, written, presentation, interpersonal) required.
• Facets experience required.
• Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams) required.

Responsibilities

• Provide claims project management oversight to ensure outcomes meet cost, efficacy, and timeliness.
• Collaborate with management across functional areas to achieve results.
• Serve as claims SME and liaison within Claims Operations and external support areas.
• Support efficiency improvements; perform PM, analyze root causes and implement corrective actions.
• Coordinate with IT, Legal, Compliance, and other departments as needed for research outcomes.
• Lead cross-functional teams to track resolution of claims issues (medical, hospital, dental) for PPO/HMO.
• Monitor claims issues to identify trends, mitigate risks, and plan corrective actions.
• Participate in QA/UAT and ensure training needs are identified for go-live.

Skills

PMI/Six Sigma certification

Health plan experience

Project leadership

Strong communication skills

Education

Bachelor's degree

Tools

Facets

MS Office

Job description

Summary of Position

• Provide Claims project management oversight to ensure that outcomes are within defined parameters of cost, efficacy, and timeliness.
• Collaborate with all levels of functional area management to effect desired outcomes related to Claims projects.
• Serve as technical and business content expert for claims; and as Claims subject matter expert both within Claims Operations oversight and with external support areas.
• Support the Claims Department with ongoing efficiency improvements; perform project management, resolve problematic claims processing issues utilizing research and analysis to determine root causes; identify and recommend corrective actions;ensure successful system and procedural modifications.
• Work directly with support areas (IT, Legal, Compliance, PFO, Customer Service and the Cognizant Claims Tower) as indicated based on outcome of research/analysis.

Job Responsibilities

• Serve as liaison between Claims functional group(s); provide guidance, directions, recommendations for issue resolution; assist with implementation of solutions; provide process improvement recommendations.
• Collaborate with end users to identify impediments to accuracy/productivity; provide direction on possible solutions.
• Lead cross-functional teams (Payment Integrity, Provider Claims Resolution, Grievance and Appeals, Provider Network Management, Customer Service) to track/monitor the resolution of Claims Issue (medical, hospital and dental) for HMO/PPO claims (Facets).
• Monitor/Analyze claims issues to identify trends, inefficiencies, and potential risks. Prepare a mitigation plan to resolve outstanding claims issues. Work with other functional areas to provide expertise and guidance where appropriate.
• Lead cross-functional teams, collaborating with business stakeholders, IT, and other departments to prioritize projects, ensure effective project execution and claims issue resolutions.
• Clarify benefits, review procedural documents and system/benefit/contract configurations to determine validity of inquiry; interface with Cognizant Claims & Analytics, IT, external vendors and other departments to address/ resolve identified issues.
• Contribute to the development of business and technical requirements for system enhancements to mediate between theory and real impact to user, and corporate projects and workflow changes.
• Participate in the development, deployment and ongoing maintenance of new technologies for Claims processing for PPO/HMO claims.
• Ensure all claims projects adhere to healthcare industry regulations and standards, such as HIPAA and other relevant guidelines. Implement strategies to improve claims processing efficiency and accuracy. Review requirements, test scenarios and provide feedback and approval on the results.
• Assist with impact analysis of production issues prior to system implementations and provide information to management and/or business partners; review technical requirements document.
• Participate in QA/UAT Test plan reviews ensuring problematic or specific scenarios are included in the test plan.
• Participate in implementation walkthroughs and review related procedural documents prior to "go live" date ensuring training needs have been identified and communicated to all affected parties.
• Manage high priority/high visibility processing project requests to completion as assigned.
• Participate in corporate projects, interdepartmental projects and meetings as the Claims representative.
• Manage receipt and assignment of projects from Provider Network Management and Customer Service which require review/reprocessing.
• Work with Cognizant Claims Tower to manage adjudication of problematic claims until system modifications are completed; vet workarounds and document workarounds to support staff education.
• Participate in review of current procedure documents (CMORE documents) that are due for annual review; identify needed updates.
• Contribute to corrective measures associated with Quality findings and remediation opportunities.
• Recommend and facilitate implementation of changes to procedures and policies that result in improved operational efficiencies. Facilitate implementation of workflow changes within Claims Tower and between support departments to improve operational efficiency.
• Request ad-hoc reports and oversee completion to ensure appropriate data is presented as per request.
• Monitor variety of reports to ensure accurate claims payment.

Qualifications

• Bachelor's degree required; additional years of experience and/or training/certifications may be considered in lieu of educational requirements
• Project Management (PMI) or Six Sigma/related certification preferred
• 4 - 6+ years' experience with claims, claims support, vendor oversight, analytics and/or UAT management required
• Health plan industry experience required
• Proven track record of successfully managing medium to large (division/department) projects required
• Experience in staff and process management in positions with a history of increasing responsibility required
• Experience utilizing metrics and analytics to define and verify outcomes and performance relative to SLAs required
• Health plan functional, operational, analytic and/or UAT domain expertise required
• Strong communication skills (verbal, written, presentation, interpersonal) required
• Facets experience required
• Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) required

Additional Information

• Hiring Range: $68,040-$118,800