Emblem Health
Operations At EmblemHealth
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.
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.