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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Sr. Claims Analyst
- 📁
- Operations
- 💼
- EmblemHealth
- 📅
- Mar 31, 2026 Post Date
Summary of Position
- Perform high dollar claim audits and provide oversight and guidance to claim analysts.
- Determine the root cause of errors and recommend appropriate corrective actions to prevent re-occurrence of these errors.
- Support business initiatives with quantitative transactional analysis and sample audits.
- Support business leaders with business improvement and integration projects.
Roles & Responsibilities
- Perform timely pre-payment audits of high dollar claims to verify the accuracy of claim payment and processing.
- Perform cycle time analysis to determine root cause and corrective actions.
- Perform comprehensive audits of adjustment transactions to verify that inquiries from groups, providers and members are resolved accurately and timely.
- Conduct special audits as directed by leadership.
- Provide problem definition/analysis support to the business leaders and their associated process improvements projects.
- Review and evaluate management responses and corrective action plans related to audit error findings.
- Work with leadership on disputed audit findings and make recommendations for corrective actions.
- Develop appropriate and cost-effective recommendations by partnering with Claims, Provider File Ops, Provider Network Mgmt., Utilization Mgmt. and IT to identify any required system logic modifications related to audit findings.
- Perform comprehensive reviews of new product or system implementations as requested by leadership.
- Participate in the external audit process by responding to specific audit issues or questions as directed.
- Make recommendations and modifications to the audit program desk level procedures (DLP’s) based on changing business environment.
- Perform other duties as assigned, directed, or required.
Qualifications
- Bachelor’s degree
- 3 – 5+ years relevant work experience, preferably in auditing and improving operational processes
- Additional years of experience and/or specialized training may be considered in lieu of educational requirements
- Extensive experience in quality and/or root cause analysis
- Working knowledge of insurance coding and/or claims experience
- Knowledge of Emblem Health’s processes and FACETS system
- Detail oriented; strong problem identifying and solving skills
- Strong communication skills (verbal, written, presentation, interpersonal)
- Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access
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 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, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected 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.