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    Sr. Claims Analyst - New York, United States - EmblemHealth

    EmblemHealth
    EmblemHealth New York, United States

    1 week ago

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    Description

    Summary of Job

    Ensure prompt, efficient, accurate and timely claims adjudication of high dollar claims in accordance with the current policy benefits, limitations or exclusions. Provide resolution of provider inquiries and collaborate with internal departments. Provide feedback or suggestions to enhance current processes and/or systems.

    Responsibilities:

    • Research and adjudicate high dollar claims, in accordance with the current policy benefits, limitations, or exclusions through a claim processing work queue.
    • Perform claim adjustments of high dollar claims and handles reconciliations of questionable claims.
    • Provide feedback or suggestion to enhance current processes and/or systems.
    • Meet or exceed all required claim productivity, quality and timeliness standards.
    • Promote delivery of highest quality of services through research and review of issues, continual evaluation and correction of root causes behind service problems.
    • Propose workflow changes to correct and enhance claim processes.
    • Work with internal departments including Sales, Legal, Provider Network Management, Provider File Operations, Customer Service, and Utilization Management to gather information needed to resolve high dollar claim issues.
    • Promote delivery of highest quality of services through research and review of issues, continual evaluation, and correction of root causes behind service problems.
    • Perform other related projects and duties as assigned, directed, or required.
    Qualifications:
    • Bachelor's Degree
    • 3 - 5+ years' claims processing experience, preferably working in an HMO, managed care or self-insured environment (Required)
    • Additional experience/specialized training/certification may be considered in lieu of degree requirements (Required)
    • Knowledge of claims processing rules and coding experience with DRG, ICD10 and CPT4 (Required)
    • FACETS system knowledge (Preferred)
    • Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) (Required)
    • Knowledge of HIPAA guidelines (Required)
    • Demonstrated leadership abilities and the ability to handle multiple simultaneous priorities and meet deadlines (Required)
    • Strong communications skills (verbal, written, presentation, interpersonal) (Required)
    • Excellent attention to detail, judgment, analytical, and problem-solving skills (Required)
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