Contribute to cost containment by negotiating Single Case Agreements on claims authorized on behalf of EmblemHealth’s network as well as out-of-network Agreements. Responsible for claim adjustments/reprocessing which include Customer Service referrals, resolution of correspondence (may include generating letters), overpayments, voids and adjustments and completion of special projects.Responsibilities:
- Contribute to corporate cost containment efforts by negotiating single case agreements on pre- and post-service claims for authorized services rendered by providers who are out of EmblemHealth’s network.
- Balance conflicting requests and obtain appropriate resolutions within EmblemHealth’s guidelines.
- Maintain detailed and accurate data for all SPAs for payment trend analysis and future contract negotiations.
- Review and investigate Out of Network professional and/or facility claims (all claim types, specialties, Lines of Business) according to organizational policies and procedures.
- Contact payers to verify benefits and eligibility, authorizations or pre-certifications (in- and out-of-network benefits).
- Analyze, research, and resolve complex claims inquiries pertaining to negotiated agreements according to the line of business and members’ benefit plan.
- Resolve the most complex claim issues with internal departments or external vendors serves as primary liaison with utilization management.
- Request billing system changes as needed.
- Support the Provider Relations team as a knowledgeable resource with the abilities to find the appropriate resolution of provider and member grievances.
- Participate in special projects related to patient research by coordinating with Payor Contracting and other departments.
- Assist with business needs-based on strong working knowledge of claims systems.
- Audit Single Case Agreement ensuring proper payments are made to satisfy Annual Internal Audit reviews.
- Support and assist Contracting Manager, in preparing monthly performance reports for senior management.
- 3 – 5 years claims background and/or minimum of 3-5 years relevant work experience
- Excellent customer service skills with a high degree of timely problem resolution
- Demonstrate strong analytical and interpretation skills with the ability to meet multiple deadlines
- Must be PC literate and possess a strong understanding of Microsoft Office applications (i.e. Excel, Access, or Word)
- Ability to manage sensitive and confidential issues
- Strong analytical skills and mathematical aptitude required
- Basic Knowledge of provider contracting methodologies and payor roles, responsibilities and challenges. An understanding of health care financing, access issues, delivery systems, quality controls, and related healthcare legislation
- Requires independent interactions with individuals at various provider organizations
- Requires excellent analytical skills both situational and financial
- Excellent communication skills, written and verbal, to ensure that the appropriate requests are articulated and that problems are resolved accurately
- Interpersonal skills to effectively maintain working relationships both internally and externally to get issues resolved
- Requires strong problem solving skills to identify root causes and appropriate resolution
We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.