Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Manager, Benefits Coordination and Claims
REMOTE
Summary of Position
- Responsible for leading and optimizing the organization’s secondary payer and revenue recovery processes across all lines of business, establishing performance metrics and accountability standards aligned with organizational goals.
- Lead, supervise, and develop a team of COB Specialists, establishing performance metrics and accountability standards aligned with organizational goals
- Ensure accurate identification and management of Other Health Insurance (OHI), compliance with CMS and regulatory requirements, and operational excellence within COB functions.
- Monitor and analyze COB metrics, denial trends, and recovery outcomes; implement process improvements to enhance operational effectiveness.
- Drive strategic initiatives to reduce claim overpayment, improve recovery outcomes, and strengthen financial performance while maintaining regulatory integrity.
Principal Accountabilities
- Oversee end-to-end COB operations, including identification and validation of Other Health Insurance (OHI), Medicare Secondary Payer (MSP) processing, and commercial coordination rules. Ensure accurate application of Medi Investigate and resolve complex COB claim denials, payment disputes, and escalated provider or member inquiries.
- Ensure accurate application of Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan COB rules.
- Ensure full compliance with Centers for Medicare & Medicaid Services (CMS) regulations, including Medicare Secondary Payer (MSP) requirements, and Section 111 quarterly filings.
- Maintain adherence to federal and state COB regulations across all product lines, including Medicaid and Exchange plans.
- Investigate and resolve complex COB claim denials, payment disputes, and escalated provider or member inquiries.
- Identify root cause of issues and work with internal teams to improve processes and close process gaps.
- Collaborate and work cross-functionally with other operational areas (Claims, Provider Network Management, Contract Configuration, Provider File Operations, Payment Integrity, etc.) to ensure root causes are remediated for both overpayment and underpayments.
- Lead internal and external compliance audits and regulatory obligations.
- Implement corrective action plans in response to audit findings, regulatory updates, or compliance reviews.
- Support internal and external audits by maintaining accurate documentation, policies, and standard operating procedures.
- Partner with Claims, Enrollment, Finance, Compliance, and IT to ensure data integrity, accurate eligibility verification, and system optimization.
- Responsible for vendor relationships and recovery audit processes, as applicable.
- Develop and deliver ongoing team training to ensure regulatory updates, policy changes, and system enhancements are effectively implemented.
- Perform other duties as assigned or required.
Qualifications
- 5 – 8+ years’ relevant work experience in claims operations within a health insurance carrier environment required
- Bachelor’s degree required; additional experience/specialized training may be considered in lieu of degree
- Demonstrated expertise in Medicare, Medicaid, Essential Plan, Exchange, and Commercial Group Health Plan Coordination of Benefits rules required
- 5+ years’ experience managing staff / processes required
- In-depth knowledge of HIPAA regulations and CMS guidelines, including Medicare Secondary Payer requirements required
- Strong understanding of COB investigative processes, overpayment recovery methodologies, and denial management required
- Proficiency with claims processing platforms such as Facets and related eligibility and enrollment systems required
- Advanced analytical skills with the ability to interpret claims data, identify trends, and implement corrective strategies required
- Excellent communication and leadership skills with the ability to drive accountability and cross-functional collaboration required
- Strong organizational and auditing skills and attention to detail with a focus on operational efficiency and compliance integrity required
- Ability to effectively organize, prioritize, and manage multiple tasks/projects with simultaneous conflicting deadlines required
- Strong analytic, decision‐making, and problem‐solving abilities required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
- Demonstrated leadership skills in a matrix environment required
- Ability to discern and identify patterns/trends of issues and provide recommendations for resolution required
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.