Summary of Position
- Proactively assess and monitor vendor operational performance to ensure contractual targets and quality expectations are met.
- Monitor and support daily financial recovery activities to ensure negative balance claims and identified overpayments are recovered timely and appropriately.
- Engage directly with Special Handling, Tier 1, and high-exposure non-special handling facilities/providers across the enterprise.
- Identify improvement opportunities and collaborate with internal and external business partners to develop action plans that resolve issues and prevent future overpayments.
Principal Accountabilities
- Strengthen claims recovery by building and maintaining effective partnerships with Emblem Providers and Provider Network Management to support overpayment identification, collection activity, and direct provider engagement.
- Monitor provider outreach/follow-up activities to ensure timely responses and resolution of identified overpayments.
- Investigate and analyze claim overpayments, review root cause findings with providers, and drive timely closure of outstanding overpayment balances.
- Analyze claims, eligibility, benefits, contracts, payment history, and reimbursement methodologies to determine recovery and negative balance opportunities.
- Perform research and analysis of refund root causes and initiate corrective action plans for issue resolution and future prevention.
- Partner cross-functionally with providers and operational areas, including Claims, Provider Network Management, Contract Configuration, Provider File Operations, and Payment Integrity, to resolve complex recovery issues, identify overpayment drivers, and support root cause remediation.
- Collaborate with Cognizant and IT to maximize system offset capabilities and expedite recovery of identified overpayments.
- Analyze overpayment data and recovery trends to recommend operational, configuration, and policy improvements that enhance payment accuracy, reduce root causes, and improve recovery performance.
- Monitor recovery inventory and productivity to ensure compliance with service level agreements and departmental performance goals.
- Investigate potential third-party liability cases, including commercial or Medicare insurance, workers' compensation, and motor vehicle insurance referrals from Claims, Billing and Enrollment, Member Services, Provider Services, reports, and mass mailing questionnaires.
- Develop reports and analyze recovery metrics to support leadership decision-making and continuous process improvement.
- Assess and monitor vendor performance across core processes to ensure contractual requirements, SLA targets, and EmblemHealth customer experience objectives are met; analyze and present SLA performance results.
- Perform transactional audits and compliance, operational, and procedural reviews to evaluate vendor quality and adherence to requirements.
- Recommend process improvements and focused reviews to strengthen vendor performance, quality, and operational effectiveness.
- Participate in system testing, implementation activities, and special projects related to recovery operations and payment integrity.
Qualifications Education, Training, Licenses, Certifications
- Bachelor's degree required; additional years of experience and/or training/certification may be considered in lieu of educational requirement
Relevant Work Experience, Knowledge, Skills, and Abilities
- 3 - 5+ years of relevant experience in auditing and assessment activities and financial recovery in a healthcare provider environment required
- Experience with Medicare Secondary Payer (MSP), Coordination of Benefits (COB), provider and member recoveries, and overpayment investigations required
- Experience interpreting CMS regulations, provider contracts, reimbursement methodologies, and health plan benefits required
- Ability to independently perform research utilizing multiple sources required
- Demonstrated experience conducting complex claim investigations and financial analysis 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 can be applied across all types of business problems required
- Ability to perform root cause analysis and implement continuous improvement methodologies required
- Ability to independently manage highly complex recovery investigations with minimal supervision required
- Ability to exercise sound judgment and make evidence-based decisions required
- Ability to identify operational risks and recommend corrective actions required
- Ability to build collaborative relationships across departments and with external business partners required
Additional Information
- Requisition ID: 1000003282
- Hiring Range: $56,160-$99,360
|
EmblemHealth
Sep 25, 2026