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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Senior Claims Adjuster (Albany)
- 📁
- Bargaining Unit
- 💼
- EmblemHealth
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- May 08, 2020 Post Date
Description of Duties:
- Evaluate medical claims that suspend within the Medical Claims System utilizing EmblemHealth’s PPO proprietary conventional coding structure. Apply all PPO Coding & Pend desktop procedures during edit resolution.
Correct claims as required for settlement utilizing established policies and procedures.
Utilizing Claims Operation’s C-More Adjudication Guidelines portal, reference QA memorandums, training guidelines, departmental memos, PRG’s, etc. and apply business rules to claims as instructed for adjudication.
As necessary, manually price claims utilizing the appropriate rate files while considering the provider’s network and the beneficiary’s insurance policy. The ability to interpret contract files and apply to adjudication of pended claims.
As needed, access PPO’s PC Helper applications such as CWI-Viewer Application, Anesthesia Calculator, PC History Look-Up and any other helper application developed by EmblemHealth to support claims processing.
Perform related duties as assigned.
Qualifications:
Knowledge of medical terminology preferred
Minimum of (1) year prior claim processing experience preferred
Ability to compose concise, clear letters
Must pass an online Data Entry Assessment
Must pass a job-related written Claims Simulation
High school diploma or GED required
Test Subjects:
- Claims Simulation & Data Entry Assessments
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
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.
Sponsorship Statement
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.