Job Details

Summary of Job

Responsible for management of all Provider Claims resolutions; ensure that all claims are handled timely and accurately. Maintain thorough knowledge of all provider contracts and translate language into Emblem terminology, with an understanding of Emblem's various processing systems including claims and provider systems to evaluate ability to process claims according to contracts. Serve as a subject matter expert in all areas of contract configuration, fee schedules/groupers, and rate reimbursement. Provide recommendations for process improvements; manage process change implementations. Fully comprehend the downstream impact of loaded rates within EmblemHealth's full claims reimbursement cycle.

Responsibilities

• Oversee a unit of claims experts to review, reconcile and resolve claims inquiries, handling all claims inventory, appeals and special handling: hire, develop, mentor, train staff; clearly communicate expectations; monitor and provide feedback; ensure appropriate levels of staffing; complete performance reviews.
• Manage performance of team for claims quality; implement corrective action plans identified for areas of direct and non-direct controls.
• Responsible for all aspects of aging inventories of Claims and Special Handling requests.
• Ensure that all claims are processed accurately and timely in accordance with regulatory and corporate metrics and requirements; coordinate with multiple departments to review the need for claim adjustments due to contract/provider/system issues.
• Present and report daily, weekly and monthly status and trends on AR Review Specialists production, quality, and claims inventory levels; offer recommendations and submit corrective action plans on improvement and consistency.
• Analyze and trend inventories, performance results, and requests to determine root cause. Evaluate opportunities to improve the handling and routing of claims using workflow system.
• Work in conjunction with other operating units to analyze results and identify areas for process and quality improvement while providing timely feedback to stakeholder functional units.
• Drive process, quality and high-performance culture that ensures timely and accurate adjudication of claims connected to NetworX, TruProvider Linkage and Claim Engines.
• Communicate and collaborate with key/oversight area such as Grievance & Appeals, Provider Network Management, Information Technology, external vendors and Vendor Management to effectively develop and implement business solutions.
• Perform other duties/tasks as directed or required.

• Bachelor's degree, preferably in a business, healthcare or operations related field, Master's preferred.
• 5 - 8 years' relevant work experience (Required)
• 3 - 5 years of experience working in a health care delivery system (Required)
• Detail Oriented; analytical ability; problem-solving skills (Required)
• Strong proficiency in Microsoft Visio, Excel, and Word (Required)
• Proven ability to identify and continuously enhance efficiencies associated with Network operations (Required)
• Ability to develop, use, interpret and apply key business metrics (Required)
• Ability to organize and lead key initiatives (Required)
• Strong written and verbal communication skills; ability to effectively communicate with all types / levels of audiences (Required)