REMOTE Summary of Position
- Develop/gather business requirements for queries needed to analyze vendor payment data.
- Utilize pre/post claim editing, auditing, and claim recovery programs that will drive incremental value year over year.
- Analyze and interpret claims, payment, and vendor data to identify, prevent, and recover overpayments, as well as to drive process improvements and cost containment.
- Leverage data analytics, competitor benchmarking, and outcomes to continually identify savings opportunities; to detect trends, discrepancies and inefficiencies, and to support corrective actions.
- Collaborate with internal teams and vendors to optimize financial recovery and ensure compliance with regulatory and contractual requirements.
- Develop mitigation strategies to avoid future overpayments/underpayments and implement plans to achieve business goals.
Principal Accountabilities
- Work directly with management on highly visible projects to understand business needs and current challenges, developing innovative solutions to meet those needs.
- Assist in the development of a comprehensive claims strategic roadmap to recover, eliminate, and prevent unnecessary medical overpayments by reviewing upstream and downstream processes.
- Assist in the design and delivery of presentations on project status and outcomes to management.
- Proactively identify and investigate payment issues, developing mitigation strategies, workflow and process impacts, root cause analysis, and member/provider impact.
- Collaborate with internal teams (Claims, COB, Provider Network Management, Finance, etc.) to integrate overpayment prevention strategies.
- Maintain and apply knowledge of current trends, practices, and developments in healthcare.
- Analyze financial recovery vendor operations to ensure compliance with contracts, regulations, internal policies, and SLAs.
- Develop and execute vendor management strategies to maximize recoveries on negative balances, offsets, and overpayments.
- Analyze vendor performance data to identify trends, gaps, and areas for corrective action or process improvement.
- Establish and track KPIs and SLAs for all vendors to drive accountability.
- Assist with the resolution of escalated issues for alignment on overpayment prevention strategies.
- Report on vendor performance, recovery metrics, and process improvement initiatives to leadership and stakeholders.
- Identify overpayment/underpayment opportunities via data mining, investigations, and quality reviews (benefit configuration, COB, claims logic, etc.).
- Collect, compile, and analyze data to measure and report on current and process enhancements. Structure large data sets to find usable information and define, design, and create reporting solutions with actionable insights.
- Create reports for internal teams, external clients, and stakeholders with data visualizations (graphs, dashboards, infographics).
- Produce standard periodic reports and ad hoc analyses as requested.
- Utilize Excel, Power BI, Tableau, and other tools to analyze performance drivers and create dashboards for selfmanaged reporting.
- May write and execute SQL queries to support data validation, reporting, and issue resolution.
- Conduct regular gap analyses of internal and vendor processes to identify and mitigate risks for overpayments.
- Perform gap analyses on claims data to identify discrepancies, compliance risks, and opportunities for process improvement.
- Identify opportunities for process enhancements to streamline workflows, reduce errors, and prevent overpayments.
- Drive continuous improvement initiatives by recommending and implementing best practices in payment integrity and overpayment prevention.
- Collaborate on the design and implementation of internal controls and process improvements.
- Monitor process designs to measure operational effectiveness and improve performance of key metrics.
- Participate in interdepartmental work groups in support of process improvement projects.
Qualifications
- 4 - 6+ years' experience in health care healthcare industry, managed care and health plan operations, including vendor contracting and oversight required
- Bachelor's degree required; additional experience/specialized training may be considered in lieu of degree
- Extensive knowledge of health care provider audit methods and provider payment methods, clinical aspects of patient care, medical terminology, and medical record/billing documentation required
- Experience in claims business process analysis, preferably in healthcare (i.e. documenting business process, gathering requirements) or claims payment/analysis required
- Experience in a hospital or managed care environment with a focus on claims data analysis, provider contracting, or decision support, especially in cost and utilization analysis required
- Understanding of NYS, CMS and Medicaid reimbursement guidelines; a working knowledge of industry coding (revenue codes, ICD 9 classifications, CPT codes, etc.). Familiarity with claim coding practices and industry issues in payment methodologies; strong problem solving, root cause analysis, critical thinking skills, and meticulous attention to detail required
- Technical knowledge of health insurance claims/Financial Recovery/Vendor Oversight required
- Proven ability to apply quantitative and/or qualitative research and data analysis techniques to improve operational processes; and to identify and interpret trends, patterns, and anomalies within complex datasets of trend information required
- Experience working with internal or external stakeholders to understand business needs and translate them into technical solutions; to manage expectations; and provide HIPAA-compliant guidance to business partners, vendors, and end-users, per industry standards for EDI protocols required
- Strong understanding of data structures, relational databases, and query logic required
- Excellent communication skills (verbal, written, presentation, collaboration, persuasion); with all types/levels of audiences; ability to influence management decisions required
- Experience in Continuous Improvement Management for Operations and process mapping/documentation required
- Energy, drive and passion for End-to-End excellence and customer experience improvement required
- Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) and other data systems required
- Proficiency in SQL for data querying/analysis; data visualization tools such as Power BI/Tableau Reporting or similar preferred
- Ability to work collaboratively with cross-functional teams required
- Skilled in presenting data findings in a clear and accessible format to both technical and non-technical audiences. Familiarity with data visualization best-practices and interactive dashboard development required
Additional Information
- Requisition ID: 1000003156
- Hiring Range: $68,040-$118,800
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EmblemHealth
May 21, 2026