Qualifications

• Bachelor's Degree required; additional experience or training may substitute for education
• 3-5 years of relevant work experience in auditing and process improvement
• Extensive experience in quality and root cause analysis is necessary
• Knowledge of insurance coding and claims processing is essential
• Familiarity with EmblemHealth processes and the Facets system is preferred
• Strong problem-solving skills along with verbal and written communication proficiency are required
• Advanced computer skills, especially in Cognos, MS Excel, and MS Access, are needed.

Responsibilities

• Perform post-payment audits to ensure accuracy in claim payments
• Conduct cycle time analyses and audits to identify root causes
• Verify the resolution of service inquiries from groups, providers, and subscribers
• Execute special audits as directed by senior management
• Assist Business Transformation Leaders with problem analysis for process improvements
• Evaluate management responses to audit findings and negotiate disputed recommendations
• Analyze audit results to pinpoint and recommend corrective actions
• Make cost-effective suggestions for process enhancements
• Collaborate with various departments to address audit findings and needed system modifications
• Engage in external audit processes by coordinating responses to specific issues
• Review new product or system implementations as requested
• Ensure system data files are updated and compliant with contractual benefits.

Benefits

• Opportunities for professional development and training
• Engagement in cross-functional business transformation initiatives
• Collaborative work environment across various departments
• Potential for involvement in impactful special projects
• Flexibility in applying problem-solving and analytical skills in real-world scenarios