Summary:
- 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.
Responsibilities:
- Assist in the development of a comprehensive, strategic roadmap to recover, eliminate, and prevent unnecessary medical-expense spending by reviewing upstream and downstream processes.
- Identify overpayment/underpayment opportunities by data mining, investigation, and quality review on benefit and/or provider configuration, rate loads, rate assignments, COB, claims payment logic, etc.
- Analyze financial recovery vendor operations to ensure compliance with contracts, regulations, internal policies and SLA's. 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. Conduct regular gap analyses of both internal and vendor processes to identify and mitigate risks for overpayments.
- Proactively identify and investigate payment issues; work with stakeholders to develop mitigation strategies to prevent future occurrences, with the ability to review impacts holistically.
- Support the execution and maintenance of a corporate claim accuracy program by optimizing pre/post claim editing, auditing, and claim recovery programs.
- 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.
- Design and implement internal controls and process improvements that support overpayment prevention and recovery. Collaborate with internal teams (Claims, COB, Provider Network Management, Finance, Payment Integrity, etc.) to integrate overpayment prevention strategies across functions.
- Serve as a liaison between vendors and internal stakeholders to resolve escalated issues and align on overpayment prevention strategies.
- Complete and analyze trending reports to identify favorable/unfavorable trends.
- Analyze departmental performance trends and assist with identifying new opportunities to streamline processes and improve performance of key metrics. Establish and track key performance indicators (KPIs) and service level agreements (SLAs) for all vendors to drive accountability.
- Assist in the development and implementation of dashboards to monitor performance. Report on vendor performance, recovery metrics, and process improvement initiatives to leadership and stakeholders.
Requirements:
- Bachelor's Degree required; additional experience/specialized training may be considered in lieu of degree
- 4 - 6+ years' experience in health care healthcare industry, managed care and health plan operations, including vendor contracting and oversight required
- Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation.
- Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes; must understand trend information and be familiar with claim coding practices and industry issues in payment methodologies required
- Strong problem solving, root cause analysis and analytical skills required
- Excellent communication skills (verbal, written, presentation); ability to interact effectively across all departments and management levels required
- Excellent collaborative skills and the ability to influence management decisions required
- Experience in Continuous Improvement Management for Operations required
- Energy, drive and passion for End-to-End excellence and customer experience improvement required
- Technical knowledge of health insurance claims/Financial Recovery/Vendor Oversight required
- Strong facilitation, oral and written communication, and presentation skills required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) and other data systems required
- Experience with developing Power BI / Tableau Reporting required
- Results driven; critical thinking; meticulous attention to detail required
Additional Information
- Requisition ID: 1000002704
- Hiring Range: $68,040-$118,800
|
EmblemHealth
Oct 10, 2025