4 - 6+ years in healthcare industry, managed care, and vendor oversight
Bachelor's degree or equivalent experience
Extensive knowledge of provider audit and payment methods
Experience in claims business process analysis
Familiarity with NYS, CMS, and Medicaid reimbursement guidelines
Technical expertise in health insurance claims and financial recovery
Proiciency with SQL and data visualization tools like Power BI/Tableau
Responsibilities
Develop business requirements for vendor payment data analysis
Utilize auditing and claim recovery programs to drive value
Analyze claims data to recover overpayments and identify process improvements
Collaborate with internal teams to enhance financial recovery efforts
Manage financial recovery vendor relationships and compliance with contracts
Create actionable reports using data analytics tools
Conduct gap analyses to improve processes and reduce overpayments
Benefits
Remote work flexibility
Collaborative team environment
Professional development opportunities
Access to cutting-edge data analytics tools
Participation in meaningful projects that influence healthcare outcomes
Full Job Description
REMOTE
Summary of Position
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.
Principal Accountabilities
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.
Qualifications
4 - 6+ years' experience in health care healthcare industry, managed care and health plan operations, including vendor contracting and oversight required
Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree
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
Proficiency in SQL for data querying/analysis; data visualization tools such as Power BI/Tableau Reporting or similar preferred
Ability to work collaboratively with cross-functional teams required
Skilled in presenting data findings in a clear and accessible format to both technical and non-technical audiences. Familiarity with data visualization best-practices and interactive dashboard development 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.
