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.
If you’re an EmblemHealth employee, unlock your career potential by signing in at the top of this page. Access your employee profile to view internal job postings and explore new opportunities.
Senior Analyst, Vendor Payment Integrity - Remote
Summary of Job
Review vendor trends and impact on care cost, member and provider experience. Perform Root Cause Analysis (RCA) to resolve payment integrity issues to resolution. Initiate project requests, develop or support the development of care cost impacts, partnering with external vendors, and/or Healthcare Economics. Support vendor relationship to ensure external and internal expectations are met.
Responsbilities
- Responsible for analyzing specific contracts in Enterprise Payment Integrity.
- Serve as a primary subject matter expert for each contract to ensure optimal contract management and outcomes.
- Evaluate feasibility of implementing interim workflow processes as a stop gap to provider abrasion and interest payments.
- Act as a point of communication and coordination with all internal business units for all issues related to vendor contracts.
- Ensure current and future state analysis is performed, business requirements and change requests are analyzed and accurately documented and aligned with business needs.
- Responsible for “end to end” contract management which includes performing all pre-contractual and implementation activities, business ownership of EPMO and IT projects, development of contract performance standards and associated penalties, root cause analysis and ongoing monitoring and oversight.
- Review content of new Payment Integrity contracts and provide input as appropriate
- Partner with business and IT to develop testing strategy, test plans and functional test cases. Participate in the development and execution of user test plans to ensure that the system design meets business needs.
- Actively participate in all related Policy Meetings, Quarterly Business Reviews, Reimbursement Policy Committees, Steering Committees.
- Create monthly savings reports and identify and address trends in comparison to established goals.
- Support budget process by creating requisitions, purchase orders, and accruals for each Payment Integrity program, to ensure program alignment with budget.
- Complete monthly invoices and reconcile against Oracle system reporting.
- Identify system enhancements and process improvements which will result in enhanced reporting and savings.
- Apply project management skills to complete related projects and assignments.
- Initiate claims to determine under and overpayments, presents outcomes and seeks appropriate business approvals.
- Identify and recommend new programs, savings opportunities, and ways to optimize current contracts.
- Evaluate feasibility of implementing interim workflow processes as a stop gap to provider abrasion and interest payments.
- Complete assigned Maestro cases in the appropriate Payment Integrity queues to ensure case closure within SLAs.
- Engage vendors and internal business units to review opportunities and lead business case development, savings opportunity analysis, and creation of EPMO or IT related projects.
Qualifications
- Bachelor’s degree
- AAPC CPC - AAPC Certified Professional Coder &/or CCS - AHIMA Certified Coding Specialist (Preferred)
- Master’s Degree (Preferred)
- 4 - 6 years or relevant, professional experience in health care contracting and management (Required)
- Strong understanding of the healthcare industry, managed care and health plan operations (Required)
- Experience in managing large, complex contracts (Required)
- Additional experience/specialized training/certifications may be considered in lieu of educational requirements (Required)
- Knowledge of accruals, invoicing and financial reporting (Required)
- Experience with performance improvement (Required)
- Ability to prioritize complex projects (Required)
- Excellent organizational and project management skills (Required)
- Proficiency in Microsoft product suite (Required)
- Knowledge of claims operating platforms (Preferred)
- Excellent communication skills; ability to interact appropriately/effectively across all departments and management levels (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.