EmblemHealth

Senior Analyst, Vendor Payment Integrity - Remote

EmblemHealth • $75K — $95K *
US-AnywhereRemote in New York, NY
Healthcare
Less than 5 years of experience
3 weeks ago
Job Overview by Ladders

Qualifications

  • Bachelor's degree required
  • AAPC CPC or CCS certification preferred
  • Master's degree preferred
  • 4-6 years of professional experience in health care contracting required
  • Strong understanding of healthcare industry, managed care, and health plans required
  • Experience managing large, complex contracts required
  • Knowledge of accruals, invoicing, and financial reporting required
  • Excellent communication and organizational skills required

Responsibilities

  • Analyze specific contracts in Enterprise Payment Integrity
  • Serve as a subject matter expert for contract management
  • Evaluate and propose interim workflow processes to mitigate issues
  • Coordinate communication across internal business units regarding vendor contracts
  • Conduct business requirements analysis and document change requests
  • Manage all stages of contract management from pre-contractual activities to oversight
  • Review new Payment Integrity contracts and provide feedback
  • Collaborate with business and IT on testing strategies and execution
  • Participate in policy and review meetings
  • Create and track monthly savings reports against goals
  • Support budgetary processes with requisitions and purchase orders
  • Identify process improvement opportunities for enhanced reporting
  • Use project management skills for various projects
  • Initiate claims resolution for under and overpayments
  • Identify new programs and opportunities to optimize contracts
  • Complete assigned cases within set service level agreements
  • Engage vendors to develop business cases and savings analyses.

Benefits

  • Comprehensive healthcare coverage
  • Professional development opportunities
  • Flexible work arrangements
  • Collaborative work environment
  • Retirement savings plan options
Full Job Description
Summary of Job

Review vendor trends and impact on care cost, member and provider experience. Perform Root Cause Analysis (RCA) to resolve payment integrity issues to resolution. Initiate project requests, develop or support the development of care cost impacts, partnering with external vendors, and/or Healthcare Economics. Support vendor relationship to ensure external and internal expectations are met.

Responsbilities
  • Responsible for analyzing specific contracts in Enterprise Payment Integrity.
  • Serve as a primary subject matter expert for each contract to ensure optimal contract management and outcomes.
  • Evaluate feasibility of implementing interim workflow processes as a stop gap to provider abrasion and interest payments.
  • Act as a point of communication and coordination with all internal business units for all issues related to vendor contracts.
  • Ensure current and future state analysis is performed, business requirements and change requests are analyzed and accurately documented and aligned with business needs.
  • Responsible for "end to end" contract management which includes performing all pre-contractual and implementation activities, business ownership of EPMO and IT projects, development of contract performance standards and associated penalties, root cause analysis and ongoing monitoring and oversight.
  • Review content of new Payment Integrity contracts and provide input as appropriate
  • Partner with business and IT to develop testing strategy, test plans and functional test cases. Participate in the development and execution of user test plans to ensure that the system design meets business needs.
  • Actively participate in all related Policy Meetings, Quarterly Business Reviews, Reimbursement Policy Committees, Steering Committees.
  • Create monthly savings reports and identify and address trends in comparison to established goals.
  • Support budget process by creating requisitions, purchase orders, and accruals for each Payment Integrity program, to ensure program alignment with budget.
  • Complete monthly invoices and reconcile against Oracle system reporting.
  • Identify system enhancements and process improvements which will result in enhanced reporting and savings.
  • Apply project management skills to complete related projects and assignments.
  • Initiate claims to determine under and overpayments, presents outcomes and seeks appropriate business approvals.
  • Identify and recommend new programs, savings opportunities, and ways to optimize current contracts.
  • Evaluate feasibility of implementing interim workflow processes as a stop gap to provider abrasion and interest payments.
  • Complete assigned Maestro cases in the appropriate Payment Integrity queues to ensure case closure within SLAs.
  • Engage vendors and internal business units to review opportunities and lead business case development, savings opportunity analysis, and creation of EPMO or IT related projects.


Qualifications
  • Bachelor's degree
  • AAPC CPC - AAPC Certified Professional Coder &/or CCS - AHIMA Certified Coding Specialist (Preferred)
  • Master's Degree (Preferred)
  • 4 - 6 years or relevant, professional experience in health care contracting and management (Required)
  • Strong understanding of the healthcare industry, managed care and health plan operations (Required)
  • Experience in managing large, complex contracts (Required)
  • Additional experience/specialized training/certifications may be considered in lieu of educational requirements (Required)
  • Knowledge of accruals, invoicing and financial reporting (Required)
  • Experience with performance improvement (Required)
  • Ability to prioritize complex projects (Required)
  • Excellent organizational and project management skills (Required)
  • Proficiency in Microsoft product suite (Required)
  • Knowledge of claims operating platforms (Preferred)
  • Excellent communication skills; ability to interact appropriately/effectively across all departments and management levels (Required)

About EmblemHealth

EmblemHealth is a non-profit health insurance company based in New York City. It is one of the largest non-profit health insurers in the United States, serving over 3 million people. EmblemHealth offers a range of health insurance plans, including HMO, PPO, and EPO plans, as well as Medicare and Medicaid plans. The company also offers wellness programs and disease management services. EmblemHealth was formed in 2006 through the merger of Group Health Incorporated (GHI) and the Health Insurance Plan of Greater New York (HIP). The company has offices in New York City and Albany, New York.
Learn more about EmblemHealth
Size
3,000 employees
Industry
Healthcare
Net Income
-$100 million
Founded
2006
5 Year Trend
-5%
Revenue
$10 billion
NASDAQ
* Ladders Estimates

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