EmblemHealth · 1 week ago
Provider Dispute Analyst
New York, NY
Full-time
Onsite
Mid, Senior Level
$56K/yr - $99K/yr
3+ years expEmblemHealth is seeking a Provider Dispute Analyst responsible for receiving, researching, and resolving provider inquiries regarding claim outcomes. The role involves performing root cause analysis, collaborating with various departments, and ensuring claims are adjusted accurately to improve efficiency and quality.
InsuranceNon ProfitWellness
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 of NetworX 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
Qualification
Required
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 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
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
Preferred
Experience managing in a BPASS model preferred
Prior proven EmblemHealth experience preferred
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
bloomberglaw.com
2025-12-06
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