Sr. Claims Project Specialist

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.

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• Provide Claims project management oversight to ensure that outcomes are within defined parameters of cost, efficacy, and timeliness.
• Collaborate with all levels of functional area management to effect desired outcomes related to Claims projects.
• Serve as technical and business content expert for claims; and as Claims subject matter expert both within Claims Operations oversight and with external support areas.
• Support the Claims Department with ongoing efficiency improvements; perform project management, resolve problematic claims processing issues utilizing research and analysis to determine root causes; identify and recommend corrective actions; ensure successful system and procedural modifications.
• Work directly with support areas (IT, Legal, Compliance, PFO, Customer Service and the Cognizant Claims Tower) as indicated based on outcome of research/analysis.

• Serve as liaison between Claims functional group(s); provide guidance, directions, recommendations for issue resolution; assist with implementation of solutions; provide process improvement recommendations.
• Collaborate with end users to identify impediments to accuracy/productivity; provide direction on possible solutions.
• Lead cross‑functional teams (Payment Integrity, Provider Claims Resolution, Grievance and Appeals, Provider Network Management, Customer Service) to track/monitor the resolution of Claims Issue (medical, hospital and dental) for HMO/PPO claims (Facets).
• Monitor/Analyze claims issues to identify trends, inefficiencies, and potential risks. Prepare a mitigation plan to resolve outstanding claims issues. Work with other functional areas to provide expertise and guidance where appropriate.
• Lead cross‑functional teams, collaborating with business stakeholders, IT, and other departments to prioritize projects, ensure effective project execution and claims issue resolutions.
• Clarify benefits, review procedural documents and system/benefit/contract configurations to determine validity of inquiry; interface with Cognizant Claims & Analytics, IT, external vendors and other departments to address/resolve identified issues.
• Contribute to the development of business and technical requirements for system enhancements to mediate between theory and real impact to user, and corporate projects and workflow changes.
• Participate in the development, deployment and ongoing maintenance of new technologies for Claims processing for PPO/HMO claims.
• Ensure all claims projects adhere to healthcare industry regulations and standards, such as HIPAA and other relevant guidelines. Implement strategies to improve claims processing efficiency and accuracy. Review requirements, test scenarios and provide feedback and approval on the results.
• Assist with impact analysis of production issues prior to system implementations and provide information to management and/or business partners; review technical requirements document.
• Participate in QA/UAT Test plan reviews ensuring problematic or specific scenarios are included in the test plan.
• Participate in implementation walkthroughs and review related procedural documents prior to “go live” date ensuring training needs have been identified and communicated to all affected parties.
• Manage high priority/high visibility processing project requests to completion as assigned.
• Participate in corporate…