EmblemHealth

Senior Financial Recovery Analyst

EmblemHealth • $95K — $115K *
New York, NY 10025In-Person
Healthcare
Less than 5 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • Bachelor's degree required; equivalent experience may be considered.
  • 3-5+ years in healthcare provider financial recovery and auditing required.
  • Expertise in Medicare Secondary Payer (MSP) and Coordination of Benefits (COB) is essential.
  • Proficient in interpreting CMS regulations, provider contracts, and reimbursement methodologies.
  • Demonstrated skills in complex claim investigations and financial analysis required.
  • Effective collaboration and communication skills are vital for influencing decisions.
  • Strong auditing capability applicable to various business challenges.

Responsibilities

  • Assess and monitor vendor performance to ensure quality and contractual adherence.
  • Support recovery activities related to negative balance claims and overpayments.
  • Engage with diverse facilities and providers to strengthen recovery efforts.
  • Analyze claims data to identify overpayment trends and drive corrective actions.
  • Collaborate with cross-functional teams to resolve complex recovery issues.
  • Develop analytical reports to facilitate leadership decision-making.
  • Participate in system testing and special projects for process improvement.

Benefits

  • Comprehensive healthcare coverage for employees and their families.
  • Ongoing professional development and training opportunities.
  • Flexible working arrangements to promote work-life balance.
  • Retirement savings plans with company contributions.
  • Generous paid time off and holidays allowance.
Full Job Description
Summary of Position
  • Proactively assess and monitor vendor operational performance to ensure contractual targets and quality expectations are met.
  • Monitor and support daily financial recovery activities to ensure negative balance claims and identified overpayments are recovered timely and appropriately.
  • Engage directly with Special Handling, Tier 1, and high-exposure non-special handling facilities/providers across the enterprise.
  • Identify improvement opportunities and collaborate with internal and external business partners to develop action plans that resolve issues and prevent future overpayments.


Principal Accountabilities
  • Strengthen claims recovery by building and maintaining effective partnerships with Emblem Providers and Provider Network Management to support overpayment identification, collection activity, and direct provider engagement.
  • Monitor provider outreach/follow-up activities to ensure timely responses and resolution of identified overpayments.
  • Investigate and analyze claim overpayments, review root cause findings with providers, and drive timely closure of outstanding overpayment balances.
  • Analyze claims, eligibility, benefits, contracts, payment history, and reimbursement methodologies to determine recovery and negative balance opportunities.
  • Perform research and analysis of refund root causes and initiate corrective action plans for issue resolution and future prevention.
  • Partner cross-functionally with providers and operational areas, including Claims, Provider Network Management, Contract Configuration, Provider File Operations, and Payment Integrity, to resolve complex recovery issues, identify overpayment drivers, and support root cause remediation.
  • Collaborate with Cognizant and IT to maximize system offset capabilities and expedite recovery of identified overpayments.
  • Analyze overpayment data and recovery trends to recommend operational, configuration, and policy improvements that enhance payment accuracy, reduce root causes, and improve recovery performance.
  • Monitor recovery inventory and productivity to ensure compliance with service level agreements and departmental performance goals.
  • Investigate potential third-party liability cases, including commercial or Medicare insurance, workers' compensation, and motor vehicle insurance referrals from Claims, Billing and Enrollment, Member Services, Provider Services, reports, and mass mailing questionnaires.
  • Develop reports and analyze recovery metrics to support leadership decision-making and continuous process improvement.
  • Assess and monitor vendor performance across core processes to ensure contractual requirements, SLA targets, and EmblemHealth customer experience objectives are met; analyze and present SLA performance results.
  • Perform transactional audits and compliance, operational, and procedural reviews to evaluate vendor quality and adherence to requirements.
  • Recommend process improvements and focused reviews to strengthen vendor performance, quality, and operational effectiveness.
  • Participate in system testing, implementation activities, and special projects related to recovery operations and payment integrity.


Qualifications

Education, Training, Licenses, Certifications
  • Bachelor's degree required; additional years of experience and/or training/certification may be considered in lieu of educational requirement


Relevant Work Experience, Knowledge, Skills, and Abilities
  • 3 - 5+ years of relevant experience in auditing and assessment activities and financial recovery in a healthcare provider environment required
  • Experience with Medicare Secondary Payer (MSP), Coordination of Benefits (COB), provider and member recoveries, and overpayment investigations required
  • Experience interpreting CMS regulations, provider contracts, reimbursement methodologies, and health plan benefits required
  • Ability to independently perform research utilizing multiple sources required
  • Demonstrated experience conducting complex claim investigations and financial analysis required
  • Ability to discern and identify patterns/trends of issues and provide recommendations for resolution required
  • Pharmacy Experience preferred
  • Excellent collaboration skills and the ability to influence management decisions required
  • Excellent communication skills (verbal, written, interpersonal) required
  • Strong auditing skills that can be applied across all types of business problems required
  • Ability to perform root cause analysis and implement continuous improvement methodologies required
  • Ability to independently manage highly complex recovery investigations with minimal supervision required
  • Ability to exercise sound judgment and make evidence-based decisions required
  • Ability to identify operational risks and recommend corrective actions required
  • Ability to build collaborative relationships across departments and with external business partners 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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