EmblemHealth · 18 hours ago
Claims Quality Oversight Analyst
New York, NY
Full-time
Onsite
Entry, Mid Level
$49K/yr - $83K/yr
2+ years expEmblemHealth is focused on overseeing the performance of vendors in claims processing to ensure compliance with their standards. The Claims Quality Oversight Analyst will perform quality assurance oversight, administer audits, and collaborate with vendors to resolve issues in claims processing.
InsuranceNon ProfitWellness
Responsibilities
Administer audits of the delegate claims processing function:
Request supporting documentation for randomly selected samples of delegate processed claims
Work with the RM to ensure that all delegate-provided information is complete prior to commencement of audit
Review all documentation and populate DVOC audit tool with claims detail for all selected samples
Review delegate’s Claims policies & procedures and score the DVOC audit tool for completeness
Conduct exit conference with delegates to discuss audit findings
Share findings with delegate and review disputes
Prepare all applicable audit memos for presentation to the DVOC (audit memo, CAP and CAP updates memos)
Administer CAPs and monitor to ensure that the corrective plans are completed and tested within timeline
Meet with delegates to discuss areas of concern in the timely resolution of identified issues
Work closely with RMs to obtain supporting documentation to support delegate’s confirmation of resolution
Analyze monthly KPI reporting packages received and prepare analysis report to share with delegate for response
Ensure completeness and adherence to claims processing TATs and all other designated claims metrics
Review for trends adversely impacting claims processing quality and highlight in written analysis
Participate in monthly Administrative Operating Committee meetings with delegates to discuss areas of concern within the claims’ metrics and status updates on implementation of open corrective actions
Qualification
Required
Bachelor's Degree; additional years of experience/specialized training may be considered in lieu of educational requirements required
2 – 3 years' experience in claims auditing required
Strong knowledge of claims processing, procedures and systems, State, Federal and Medicare Regulations required
Excellent organizational and time management skills required
Extensive knowledge of professional and facility claims processing systems required
Strong analytical and deductive evaluation skills to anticipate and resolve potential claim systems discrepancies and the ability to propose effective solutions required
Proficiency with MS Office applications (Word, Excel, Access, etc.) required
Effective communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences required
Preferred
1+ years' experience working in BPASS model 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
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