Claims Review Analyst

Emblem Health 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, Emblem Health partners with top hospitals and doctors, including its own Advantage Care Physicians, to deliver quality, affordable, convenient care.

At over a dozen Emblem Health Neighborhood Care locations, members and non‑members alike have access to community‑based health and wellness guidance and resources. For more information,  .

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• 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.
• 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 provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
• Conduct regular meetings with the assigned provider groups for status of AR files and recycles
• Support departmental goals for cycle time by organizing and tracking claims for review.
• Monitor and provide timely responses for the designated provider group emails and AR files.
• Perform other related tasks as directed or required.

• Bachelor’s degree ; additional experience/specialized training may be considered in lieu of educational requirements required
• 2 – 3 years’ prior related work experience in professional/facility claims or benefits/billing environment required
• Strong knowledge of claim processing policies and procedures required
• Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
• Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required
• Ability to accurately interpret information from contractual and technical perspectives required
• Must be conscientious and detail oriented; ability to recognize unusual patterns and troubleshoot for operational improvement and efficiencies required
• Strong analytical and problem‑solving skills required
• Ability to effectively work on multiple projects/tasks with competing priority levels and deadlines required
• Ability to effectively absorb and communicate information required
• Strong Interpersonal and teamwork skills required

• Requisition :
• Hiring Range: $48,600-$83,160

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At Emblem Health, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typical new hires may not start at the top of this range, as…