EmblemHealth
06/25/2022  
Summary of Position • Responsible for implementing, validating, and ensuring the optimal functioning of all call center and customer satisfaction related systems, resources, and tools. • Ensure data integrity, minimize interruption of call center systems and workforce management functions. • Actively participate in execution of strategic, analytical, and technical projects. Develop strong business acumen through data analysis, industry trend, market research, customer satisfaction survey to identify strategic opportunity on the horizon. • Partner with Operations leadership to promote omni-channel, introduce new technology solutions to improve the member experience and achieve process efficiency. Principal Accountabilities • Partner with the IT infrastructure, information security and vendor’s project implementation team to ensure call center systems are running at the optimal level; ensure continuity of service and data alignment across all areas. • Serve as the...
EmblemHealth New York, NY, United States Full Time
06/25/2022  
Summary of Job: Serve as pharmacy systems coding subject matter expert with a focus on medical drug claim processing, review of utilization management, PA processing, and appeals. Support and sponsor pharmacy system projects/implementation for medical drug claims and medical PA. Provide technical and SME support for projects. Liaison between IT and any key stakeholders/vendors/pharmacy systems or systems owners. Responsibilities: Collaborate in defining, gathering, reviewing, and editing business requirements for system updates, enhancements and migrations for claims projects. Manage all project documentation for presentation and reporting; ex. business requirements, test packet, status and prioritization for a variety of audiences including Senior Management, Care Management, Pharmacy Services and CM Data Systems customers. Perform solution analysis review and provide concise direction to ensure that the proposed system solution meets established business...
EmblemHealth New York, NY, United States Full Time
06/24/2022  
Will extract, analyze and interpret data to produce both standard claims and utilization trend reporting and ad hoc analysis requests. Supports all functions within Medical Economics including monitoring of specific corporate and health cost containment initiatives. Responsibilities: Supports research and analysis of financial data, draws conclusions and provides consultation to internal and external partners for use in administering specific programs and processes related to medical expense and utilization. May create comparative views of unit cost information that contracting teams can utilize to identify outlier contracts.  Conducts ongoing monitoring of medical cost savings initiatives. Assist the business units to identify trend outliers, analyze the trend drivers and perform the work necessary to facilitate the discussion on possible solutions. Performs detailed analyses, including accumulation of data, financial modeling, and reporting of outcomes....
EmblemHealth New York, NY, United States Full Time
06/24/2022  
We are seeking dynamic Medicare Customer Service Associates to join our Call Center in Farmington, CT starting February 2022! The Medicare Customer Service Associate will provide telephonic customer service support to ConnectiCare members, providers and facilities. Inquiries can range from verifying information, question regarding bill, locating a Physician in accordance to their plan, etc. They will be responsible for addressing any issues under ConnectiCare’s various plans as it relates to areas of coverage, payment of claims, membership status, medical management intake calls, etc. Description of Duties: Receives and responds to telephone calls and correspondence from members, regarding billing, benefits, coverage, payment, coding, and health services policies and procedures. Maintains telephone log documenting number, content and type of calls received. Explains medical pre-authorization requirements and disposition of pre-authorization requests, as necessary....
EmblemHealth Farmington, CT, United States Full Time
06/24/2022  
Summary of Job: Responsible for the data and reporting necessary to support EmblemHealth’s Sales Operations team to meet sales and business objectives for EmblemHealth.  Leverage practical process, data, and technology solutions to deliver timely sales reporting.   Collaborate with internal stakeholders to enhance sales reporting and operation processes that balances both the needs of the company and sales efficiency. Deliver critical reporting and data analysis in support of client growth and retention. Work collaboratively with others across Data, Sales, Product, Medical Economics, Account Management and Finance to deliver on Sales operations activities.  Serve as a key operational partner to our client-facing and revenue producing teams. Requirements: Provide network sales support: repricing and analysis of claim discount information.  Serve as point person with Cognizant for producing reports and requirements. Participate in external/internal conference calls....
EmblemHealth New York, NY, United States Full Time
06/24/2022  
We are seeking dynamic Customer Service Representatives to join our Call Center in Syracuse, NY starting February 2022! The Customer Service Representative will provide customer service support to EmblemHealth members. Inquiries can range from verifying information, question regarding bill, locating a Physician in accordance to their plan, etc. They will be responsible for addressing any issues under EmblemHealth’s various plans as it relates to areas of coverage, payment of claims, membership status, medical management intake calls, etc. Description of Duties: Receive, answer and/or record telephone/correspondence/e-mail inquiries from subscribers, providers, and other consumers relating to areas of coverage, payment of claims, membership status, medical management intake calls, etc., under the various EmblemHealth medical/surgical, dental, hospital and Medicare plans. Review inquiries, correspondence, and email receipts. Prepare email resolutions, letters (form or...
EmblemHealth East Syracuse, NY, United States Full Time
06/24/2022  
We are seeking dynamic Customer Service Representatives to join our Call Center in Albany, NY starting February 2022! The Customer Service Representative will provide customer service support to EmblemHealth members. Inquiries can range from verifying information, question regarding bill, locating a Physician in accordance to their plan, etc. They will be responsible for addressing any issues under EmblemHealth’s various plans as it relates to areas of coverage, payment of claims, membership status, medical management intake calls, etc. Description of Duties: Receive, answer and/or record telephone/correspondence/e-mail inquiries from subscribers, providers, and other consumers relating to areas of coverage, payment of claims, membership status, medical management intake calls, etc., under the various EmblemHealth medical/surgical, dental, hospital and Medicare plans. Review inquiries, correspondence, and email receipts. Prepare email resolutions, letters (form or...
EmblemHealth Albany, NY, United States Full Time
06/24/2022  
Summary of Job: Serve as pharmacy systems coding subject matter expert with a focus on medical drug claim processing, review of utilization management, PA processing, and appeals. Support and sponsor pharmacy system projects/implementation for medical drug claims and medical PA. Provide technical and SME support for projects. Liaison between IT and any key stakeholders/vendors/pharmacy systems or systems owners. Responsibilities: Collaborate in defining, gathering, reviewing, and editing business requirements for system updates, enhancements and migrations for claims projects. Manage all project documentation for presentation and reporting; ex. business requirements, test packet, status and prioritization for a variety of audiences including Senior Management, Care Management, Pharmacy Services and CM Data Systems customers. Perform solution analysis review and provide concise direction to ensure that the proposed system solution meets established business...
EmblemHealth New York, NY, United States Full Time
06/24/2022  
Description of Duties: Handle sales administration of client’s benefit plan by initiating follow-up to resolution of all service inquiries involving claims, membership, billing, interpretation of contract provisions, benefits/plan design, and other administrative requests originating from client groups in a timely fashion. Assist with preparing renewals of existing groups by coordinating and submitting quotes and working with Underwriting and other internal departments as needed.  Assist sales staff to present and successfully close client renewals by carefully analyzing the renewal prior to release to the client and preparing material to support the renewal proposal. Working with sales staff, participate in visits with clients and/or their consultants, and keep clients informed of issues that may impact benefits and rates.  Work with sales staff to ensure client satisfaction, retention and growth by collaborating effectively with other areas of EmblemHealth to...
EmblemHealth New York, NY, United States Full Time
06/24/2022  
Build, optimize and enhance our insurance networks through relationship development with key local network participants. Act as a liaison and operates as a vital link between specific Facility, Ancillary, Delegated and/or Professional providers and EmblemHealth. Develop provider contracting efforts, including but not limited to process oversight, strategic diligence, outreach, and contract negotiations. Responsible for day to day operations for all activities related to contracts, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as communication of Plan policies and procedures.  Contact for all escalated issues from the Provider and internal EmblemHealth departments, including grievances, disputes, and provider/member billing complaints.   Note: “Provider” can include managing entity for health systems, facilities such as a specialty office, large faculty and group practices, delegated relationships,...
EmblemHealth New York, NY, United States
06/22/2022  
Manages the day-to-day responsibilities of telephone performance, coaching/counseling the customer service team and managing the inventories of offline work including eCorrespondence, social media, and HIPAA/Privacy form updates.   Responsible for systemic testing related to updates to the CRM and the website portal and assisting in training initiatives.   Drives weekly meetings with call center management of other call centers and regularly attends configuration/grooming sessions for new systems and software. Responsibilities: Monitors staff production and performance in order to meet corporate performance goals.  Provides ongoing coaching and feedback to staff. Coaches staff with appropriate resolution of sensitive calls of a priority nature. Answers the most complex telephone inquiries. Identifies and coordinates staff training needs to ensure uniform professional responses.   Plans and organizes the daily operation of the Service Department, including...
EmblemHealth Albany, NY, United States Full Time
06/22/2022  
Summary of Job: Responsible for the data and reporting necessary to support EmblemHealth’s Sales Operations team to meet sales and business objectives for EmblemHealth.  Leverage practical process, data, and technology solutions to deliver timely sales reporting.   Collaborate with internal stakeholders to enhance sales reporting and operation processes that balances both the needs of the company and sales efficiency. Deliver critical reporting and data analysis in support of client growth and retention. Work collaboratively with others across Data, Sales, Product, Medical Economics, Account Management and Finance to deliver on Sales operations activities.  Serve as a key operational partner to our client-facing and revenue producing teams. Requirements: Provide network sales support: repricing and analysis of claim discount information.  Serve as point person with Cognizant for producing reports and requirements. Participate in external/internal conference calls....
EmblemHealth New York, NY, United States Full Time
06/22/2022  
Build, optimize and enhance our insurance networks through relationship development with key local network participants. Act as a liaison and operates as a vital link between specific Facility, Ancillary, Delegated and/or Professional providers and EmblemHealth. Develop provider contracting efforts, including but not limited to process oversight, strategic diligence, outreach, and contract negotiations. Responsible for day to day operations for all activities related to contracts, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as communication of Plan policies and procedures.  Contact for all escalated issues from the Provider and internal EmblemHealth departments, including grievances, disputes, and provider/member billing complaints.   Note: “Provider” can include managing entity for health systems, facilities such as a specialty office, large faculty and group practices, delegated relationships,...
EmblemHealth New York, NY, United States
06/22/2022  
Support contract performance management of a large health system. Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines. Identify and analyze single issues and trends to determine root causes. Provide recommendations for solutions to minimize errors and delays in systems and/or processes. Monitor system output to ensure proper functioning. Responsibilities: Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review. Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely. Track issues and monitor trends to support their resolution. Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management. Improve quality, enhance workflow, and...
EmblemHealth New York, NY, United States Full Time
06/22/2022  
Summary of Job: Serve as pharmacy systems coding subject matter expert with a focus on medical drug claim processing, review of utilization management, PA processing, and appeals. Support and sponsor pharmacy system projects/implementation for medical drug claims and medical PA. Provide technical and SME support for projects. Liaison between IT and any key stakeholders/vendors/pharmacy systems or systems owners. Responsibilities: Collaborate in defining, gathering, reviewing, and editing business requirements for system updates, enhancements and migrations for claims projects. Manage all project documentation for presentation and reporting; ex. business requirements, test packet, status and prioritization for a variety of audiences including Senior Management, Care Management, Pharmacy Services and CM Data Systems customers. Perform solution analysis review and provide concise direction to ensure that the proposed system solution meets established business...
EmblemHealth New York, NY, United States Full Time
06/21/2022  
Summary of Job: Responsible for the data and reporting necessary to support EmblemHealth’s Sales Operations team to meet sales and business objectives for EmblemHealth.  Leverage practical process, data, and technology solutions to deliver timely sales reporting.   Collaborate with internal stakeholders to enhance sales reporting and operation processes that balances both the needs of the company and sales efficiency. Deliver critical reporting and data analysis in support of client growth and retention. Work collaboratively with others across Data, Sales, Product, Medical Economics, Account Management and Finance to deliver on Sales operations activities.  Serve as a key operational partner to our client-facing and revenue producing teams. Requirements: Provide network sales support: repricing and analysis of claim discount information.  Serve as point person with Cognizant for producing reports and requirements. Participate in external/internal conference calls....
EmblemHealth New York, NY, United States Full Time
06/21/2022  
Summary Provide financial services and analyses in support of Government Programs business.  Manage Medicaid MMCOR filing, financial performance tracking, and other ad hoc analysis. Responsibilities Provide oversight of quarterly MMCOR & EPPOR filings; implement changes to reporting requirements; answer questions from the State on the filings. Support analysis of hospital, professional, and drug claims experience; measure utilization levels and trends; evaluate cost and intensity levels and trends; and perform various other analyses related to Government LOBs. Support accounting and actuarial during the month end close process by providing guidance and feedback related to accruals and performing variance analysis, etc. Track comparisons between MMCOR/EPPOR and EIS, respond to the State on discrepancies and participate in strategy to close gaps. Provide support for other areas of the business that pertain to Government Programs business. Regular...
EmblemHealth New York, NY, United States Full Time
06/21/2022  
Support contract performance management of a large health system. Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines. Identify and analyze single issues and trends to determine root causes. Provide recommendations for solutions to minimize errors and delays in systems and/or processes. Monitor system output to ensure proper functioning. Responsibilities: Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review. Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely. Track issues and monitor trends to support their resolution. Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management. Improve quality, enhance workflow, and...
EmblemHealth New York, NY, United States Full Time
06/16/2022  
Summary of Position •   Independently investigate and respond to written/verbal appeals submitted by members, employees, contracted and non-contracted providers, Department of Financial Services (DFS), Attorney General (AG), Department of Health (DOH), Executive or Congressional branches with customized responses based on the issues presented by the appellant.  Complete responses in accordance with Emblem Health policies and procedures as well as the regulations by NCQA, CMS, NY State and other entities.   •   The types of correspondence handled by the individual will include, but are not limited to, prompt-pay inquiries, complaints, administrative and utilization review appeals, second level complaints, second level administrative appeals, Medicare standard, and Expedited appeals for all lines of business. •   Review complex cases, analyze and summarize for senior management and regulatory entities.   •   Responsible for mentoring specialists and providing assistance to...
EmblemHealth New York, NY, United States Full Time
06/15/2022  
Support contract performance management of a large health system. Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines. Identify and analyze single issues and trends to determine root causes. Provide recommendations for solutions to minimize errors and delays in systems and/or processes. Monitor system output to ensure proper functioning. Responsibilities: Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review. Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely. Track issues and monitor trends to support their resolution. Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management. Improve quality, enhance workflow, and...
EmblemHealth New York, NY, United States Full Time