EmblemHealth · 3 weeks ago
Senior Business Analyst, Claims and Vendor Data
New York, NY
Full-time
Onsite
Mid, Senior Level
$68K/yr - $119K/yr
4+ years expEmblemHealth is a healthcare organization focused on providing quality services. They are seeking a Senior Business Analyst to develop business requirements for vendor payment data analysis and to optimize financial recovery processes.
InsuranceNon ProfitWellness
Responsibilities
Develop/gather business requirements for queries needed to analyze vendor payment data
Utilize pre/post claim editing, auditing, and claim recovery programs that will drive incremental value year over year
Analyze and interpret claims, payment, and vendor data to identify, prevent, and recover overpayments, as well as to drive process improvements and cost containment
Leverage data analytics, competitor benchmarking, and outcomes to continually identify savings opportunities; to detect trends, discrepancies and inefficiencies, and to support corrective actions
Collaborate with internal teams and vendors to optimize financial recovery and ensure compliance with regulatory and contractual requirements
Develop mitigation strategies to avoid future overpayments/underpayments and implement plans to achieve business goals
Work directly with management on highly visible projects to understand business needs and current challenges, developing innovative solutions to meet those needs
Assist in the development of a comprehensive claims strategic roadmap to recover, eliminate, and prevent unnecessary medical overpayments by reviewing upstream and downstream processes
Assist in the design and delivery of presentations on project status and outcomes to management
Proactively identify and investigate payment issues, developing mitigation strategies, workflow and process impacts, root cause analysis, and member/provider impact
Collaborate with internal teams (Claims, COB, Provider Network Management, Finance, etc.) to integrate overpayment prevention strategies
Maintain and apply knowledge of current trends, practices, and developments in healthcare
Analyze financial recovery vendor operations to ensure compliance with contracts, regulations, internal policies, and SLAs
Develop and execute vendor management strategies to maximize recoveries on negative balances, offsets, and overpayments
Analyze vendor performance data to identify trends, gaps, and areas for corrective action or process improvement
Establish and track KPIs and SLAs for all vendors to drive accountability
Assist with the resolution of escalated issues for alignment on overpayment prevention strategies
Report on vendor performance, recovery metrics, and process improvement initiatives to leadership and stakeholders
Identify overpayment/underpayment opportunities via data mining, investigations, and quality reviews (benefit configuration, COB, claims logic, etc.)
Collect, compile, and analyze data to measure and report on current and process enhancements
Structure large data sets to find usable information and define, design, and create reporting solutions with actionable insights
Create reports for internal teams, external clients, and stakeholders with data visualizations (graphs, dashboards, infographics)
Produce standard periodic reports and ad hoc analyses as requested
Utilize Excel, Power BI, Tableau, and other tools to analyze performance drivers and create dashboards for self-managed reporting
May write and execute SQL queries to support data validation, reporting, and issue resolution
Conduct regular gap analyses of internal and vendor processes to identify and mitigate risks for overpayments
Perform gap analyses on claims data to identify discrepancies, compliance risks, and opportunities for process improvement
Identify opportunities for process enhancements to streamline workflows, reduce errors, and prevent overpayments
Drive continuous improvement initiatives by recommending and implementing best practices in payment integrity and overpayment prevention
Collaborate on the design and implementation of internal controls and process improvements
Monitor process designs to measure operational effectiveness and improve performance of key metrics
Participate in interdepartmental work groups in support of process improvement projects
Qualification
Required
Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree
4 – 6+ years' experience in health care healthcare industry, managed care and health plan operations, including vendor contracting and oversight required
Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation required
Experience in claims business process analysis, preferably in healthcare (i.e. documenting business process, gathering requirements) or claims payment/analysis required
Experience in a hospital or managed care environment with a focus on claims data analysis, provider contracting, or decision support, especially in cost and utilization analysis required
Understanding of NYS, CMS and Medicaid reimbursement guidelines; a working knowledge of industry coding (revenue codes, ICD 9 classifications, CPT codes, etc.). Familiarity with claim coding practices and industry issues in payment methodologies; strong problem solving, root cause analysis, critical thinking skills, and meticulous attention to detail required
Technical knowledge of health insurance claims/Financial Recovery/Vendor Oversight required
Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes; and to identify and interpret trends, patterns, and anomalies within complex datasets of trend information required
Experience working with internal or external stakeholders to understand business needs and translate them into technical solutions; to manage expectations; and provide HIPAA-compliant guidance to business partners, vendors, and end-users, per industry standards for EDI protocols required
Strong understanding of data structures, relational databases, and query logic required
Excellent communication skills (verbal, written, presentation, collaboration, persuasion); with all types/levels of audiences; ability to influence management decisions required
Experience in Continuous Improvement Management for Operations and process mapping/documentation required
Energy, drive and passion for End-to-End excellence and customer experience improvement required
Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) and other data systems required
Ability to work collaboratively with cross-functional teams required
Preferred
Proficiency in SQL for data querying/analysis; data visualization tools such as Power BI/Tableau Reporting or similar preferred
Familiarity with data visualization best-practices and interactive dashboard development required
Skilled in presenting data findings in a clear and accessible format to both technical and non-technical audiences required
Company
EmblemHealth
EmblemHealth is an insurance and wellness company that offers health benefits to consumers, employers, and government purchasers.
1001-5000 employees
H1B Sponsorship
EmblemHealth has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2024 (2)
2023 (2)
2021 (2)
2020 (4)
Funding
Current Stage
Late StageLeadership Team
M
Michael Collins
Vice President CRM Applications
Recent News
2025-12-10
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2025-12-06
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