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 Financial Recovery & COB Analyst
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- Manager & Professional
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- ConnectiCare
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- Nov 16, 2022 Post Date
Summary of Position:
- Continuously and proactively assess and monitor vendor operations performance to ensure contractual targets and quality expectations are met.
- Responsible for daily monitoring and support of all financial recovery efforts to ensure claims in a negative balance and/or overpayment identifications are recovered timely and appropriately.
- Work directly with special handling, Tier 1 and high exposure non special handling facilities across the enterprise.
- Identify areas of improvements and work with internal and external business partners to provide appropriate action plans for resolution and prevention of future claim overpayments.
Responsibilities:
- Enhance recovery of claims by fostering partnerships with CCI/Emblem Providers and Provider Network Management related to overpayment and collection activity via direct provider contact.
- Ensure timely response from providers on overpayments.
- Investigate and analyze claim overpayments and discuss overpayment root cause with providers to ensure rapid closure of outstanding overpayment balances.
- Responsible for recoupment and reconciliation of negative balance opportunities.
- Conduct research and analysis of refund root cause and initiate corrective action plans for future prevention and issue resolution.
- Collaborate and work cross-functionally with other operational areas (Claims, Provider Network Management, Contract Configuration, Provider File Operations, Payment Integrity, etc.) to ensure causes of overpayments are understood and root causes are ultimately remediated.
- Collaborate with the Cognizant vendor and IT to ensure full advantage of system offset capabilities is taken to expedite recovery of overpayments.
- Analyze overpayment data to identify opportunities for improvement in financial recovery processes and reduction of overpayment root causes.
- Thoroughly investigate all possible third-party liability cases (Commercial/Medicare Insurance, Workers Comp, Motor Vehicle Insurance) that are referred by Claims Staff, Billing and Enrollment, Member Services, Provider Services,Reports or Mass Mailing Questionnaires.
- Monitor vendor COB transactional quality and deliverables.
- Analyze data to identify additional COB opportunities.
- Assess and monitor performance of vendors for each core process to meet contractual requirements and align with EmblemHealth/CCI customer experience objectives. Includes SLA performance review analysis Conduct reviews, transactional audits, and compliance and operational procedure reviews.
- Make suggestions for process improvements and focused reviews to enhance vendor quality.
Qualifications:
- BS or BA degree required; additional experience/specialized training may be considered in lieu of educational requirement
- 3 – 5+ years of relevant experience in auditing and assessment activities, preferably in a healthcare provider environment required
- Ability to independently perform research utilizing multiple sources required
- Ability to discern and identify patterns/trends of issues and provide recommendations for resolution required
- Pharmacy experience preferred
- Excellent collaboration skills and the ability to influence management decisions required
- Excellent communication skills (verbal, written, interpersonal) required
- Strong auditing skills that be applied across all types of business problems required
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.