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Senior Quality Analyst (PMO)

Job Description

  • Perform audits and/or provide oversight and guidance to Claim Auditors in completing comprehensive random audits of claims, membership and service inquiry adjustment transactions. 
  • Determine the root causes of error and recommend appropriate corrective actions to prevent re-occurrence of these errors. 
  • Support cross-functional Business Transformation initiatives with quantitative transactional analyses and sample audits. 
  • Support Business Transformation Leaders leading business improvement and integration projects with problem definition and resolution. 

Responsibilities:

  • Perform timely post-payment audits of all claim types to verify the accuracy of the claim payment and processing.
  • Perform cycle time analysis and audits of EmblemHealth of root cause and corrective actions 
  • Perform comprehensive audits of service inquiry adjustment transactions to verify that inquiries from groups, providers and subscribers are resolved accurately and timely. 
  • Conduct special audits as directed by senior management, including subcontracted operational capabilities.
  • Provide problem definition/analysis support to the Business Transformation Leaders and their associated process improvements projects.   
  • Review and evaluate management responses and corrective action plans related to audit findings; negotiate disputed findings and recommendations with area management.    
  • Analyze all audit results and identify the root causes of errors. 
  • Develop appropriate and cost-effective recommendations 
  • Work with Claims, PFO, PNM, Membership and IT to identify any required system logic modifications related to audit findings.   
  • Participate in the external audit process, provide instruction to the auditors, research and coordinate responses to specific audit issues or to questions as directed by departmental management.   
  • Perform comprehensive reviews of new product or system implementations, as requested by management. 
  • Verify that applicable system data files are updated and claims are accurately adjudicated in accordance with contractual benefit provisions in conjunction with the reviews.   
  • Regular attendance is an essential function of the job.  Perform other duties as assigned or required.   

Job Requirements

Requirements:

  • Bachelor’s Degree required; additional years of experience and/or specialized training may be used in lieu of educational requirements
  • 3 – 5 years relevant work experience required, preferably in auditing and improving operational processes
  • Prior extensive experience in quality and/or root cause analysis required
  • Prior knowledge in insurance coding and/or claims experience required
  • Facets system knowledge preferred 
  • Strong problem solving and verbal and written communication skills required
  • Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access required
  • Ability to travel between Emblem operational sites, as required

Job Snapshot

Location US-NY-New York
Employment Type Full-Time
Pay Type Year
Pay Rate N/A
Store Type Health Care
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Company Overview

EmblemHealth

EmblemHealth is a local, neighborhood health plan that has served the New York City area and surrounding communities for more than 75 years. That’s the kind of experience that makes us unique. We’re proud to be one of the nation’s largest not-for-profit health plans, serving 3.1 million people who live and work across the New York tri-state area. Learn More

Contact Information

US-NY-New York
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Snapshot
EmblemHealth
Company:
US-NY-New York
Location:
Full-Time
Employment Type:
Year
Pay Type:
N/A
Pay Rate:
Health Care
Store Type:

Job Description

  • Perform audits and/or provide oversight and guidance to Claim Auditors in completing comprehensive random audits of claims, membership and service inquiry adjustment transactions. 
  • Determine the root causes of error and recommend appropriate corrective actions to prevent re-occurrence of these errors. 
  • Support cross-functional Business Transformation initiatives with quantitative transactional analyses and sample audits. 
  • Support Business Transformation Leaders leading business improvement and integration projects with problem definition and resolution. 

Responsibilities:

  • Perform timely post-payment audits of all claim types to verify the accuracy of the claim payment and processing.
  • Perform cycle time analysis and audits of EmblemHealth of root cause and corrective actions 
  • Perform comprehensive audits of service inquiry adjustment transactions to verify that inquiries from groups, providers and subscribers are resolved accurately and timely. 
  • Conduct special audits as directed by senior management, including subcontracted operational capabilities.
  • Provide problem definition/analysis support to the Business Transformation Leaders and their associated process improvements projects.   
  • Review and evaluate management responses and corrective action plans related to audit findings; negotiate disputed findings and recommendations with area management.    
  • Analyze all audit results and identify the root causes of errors. 
  • Develop appropriate and cost-effective recommendations 
  • Work with Claims, PFO, PNM, Membership and IT to identify any required system logic modifications related to audit findings.   
  • Participate in the external audit process, provide instruction to the auditors, research and coordinate responses to specific audit issues or to questions as directed by departmental management.   
  • Perform comprehensive reviews of new product or system implementations, as requested by management. 
  • Verify that applicable system data files are updated and claims are accurately adjudicated in accordance with contractual benefit provisions in conjunction with the reviews.   
  • Regular attendance is an essential function of the job.  Perform other duties as assigned or required.   

Job Requirements

Requirements:

  • Bachelor’s Degree required; additional years of experience and/or specialized training may be used in lieu of educational requirements
  • 3 – 5 years relevant work experience required, preferably in auditing and improving operational processes
  • Prior extensive experience in quality and/or root cause analysis required
  • Prior knowledge in insurance coding and/or claims experience required
  • Facets system knowledge preferred 
  • Strong problem solving and verbal and written communication skills required
  • Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access required
  • Ability to travel between Emblem operational sites, as required

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