Talent.com
Sr. Claims Project Specialist

Sr. Claims Project Specialist

EmblemHealthNew York, NY, United States
Hace 12 horas
Tipo de contrato
  • A tiempo completo
Descripción del trabajo

Summary of Position

  • 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.

Job Responsibilities

  • 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 projects, interdepartmental projects and meetings as the Claims representative.
  • Manage receipt and assignment of projects from Provider Network Management and Customer Service which require review / reprocessing.
  • Work with Cognizant Claims Tower to manage adjudication of problematic claims until system modifications are completed; vet workarounds and document workarounds to support staff education.
  • Participate in review of current procedure documents (CMORE documents) that are due for annual review; identify needed updates.
  • Contribute to corrective measures associated with Quality findings and remediation opportunities.
  • Recommend and facilitate implementation of changes to procedures and policies that result in improved operational efficiencies. Facilitate implementation of workflow changes within Claims Tower and between support departments to improve operational efficiency.
  • Request ad-hoc reports and oversee completion to ensure appropriate data is presented as per request.
  • Monitor variety of reports to ensure accurate claims payment.

    • Qualifications

  • Bachelor's Degree
  • Project Management (PMI) or Six Sigma / related certification preferred
  • 4 - 6+ years' experience with claims, claims support, vendor oversight, analytics and / or UAT management required
  • Health plan industry experience required
  • Proven track record of successfully managing medium to large (division / department) projects required
  • Experience in staff and process management in positions with a history of increasing responsibility required
  • Additional years of experience and / or training / certifications may be considered in lieu of educational requirements required
  • Experience utilizing metrics and analytics to define and verify outcomes and performance relative to SLAs required
  • Health plan functional, operational, analytic and / or UAT domain expertise required
  • Strong communication skills (verbal, written, presentation, interpersonal) required
  • Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc.) required

    • Additional Information

    Requisition ID : 1000002775

    Hiring Range : $68,040-$118,800

    Crear una alerta de empleo para esta búsqueda

    Sr Project Specialist • New York, NY, United States

    Ofertas relacionadas
    • Oferta promocionada
    Sr. Claims Specialist

    Sr. Claims Specialist

    W.R. BerkleyJersey City, NJ, US
    A tiempo completo
    This individual would be responsible for reviewing, processing, investigating, evaluating, negotiating and the settling of assigned property damage or bodily injury claims with the authority level ...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    Senior Environmental Technical Claims Specialist

    Senior Environmental Technical Claims Specialist

    Argonaut Management Services, IncNewark, NJ, United States
    A tiempo completo
    Argo Group International Holdings, Inc.American National, US based specialty P&C companies, (together known as BP&C, Inc. Brookfield Wealth Solutions, Ltd.BWS"), a New York and Toronto-listed public...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    Side Hustle Project Lead

    Side Hustle Project Lead

    Finance BuzzOld Bridge, New Jersey, US
    A tiempo completo +1
    We’re offering a role for someone who wants to lead their own side-income project in their spare time.You’ll explore various proven side hustles, select the ones that fit your lifestyle, and run th...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    Construction Defect Claims Specialist

    Construction Defect Claims Specialist

    AmTrust FinancialNew York, NY, United States
    A tiempo completo
    Construction Defect Claims Specialist.Amtrust Financial Services, a fast growing commercial insurance company, is seeking a Construction Defect Claims Specialist. This position can be located in one...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    MRSGM NA Claims Resolution Specialist, Cyber

    MRSGM NA Claims Resolution Specialist, Cyber

    Munich RENew York, NY, United States
    A tiempo completo
    Schaumburg, United States; Houston, United States; Long Beach, United States; Miami Gardens, United States; Miami, United States. Mt.Pleasant, United States; New York, United States;.Munich Re Spec...Mostrar másÚltima actualización: hace 2 días
    • Oferta promocionada
    Claims Specialist

    Claims Specialist

    Metro Public AdjustmentWayne, NJ, US
    A tiempo completo +1
    Claim Specialist; Part time or Full time with flexible hours.Contractor, Home Inspector, Realtor, mortgage broker, real estate licensee, appraiser, contractor or related field? Learn to put your sk...Mostrar másÚltima actualización: hace 1 día
    • Oferta promocionada
    Claims Specialist II

    Claims Specialist II

    NY StaffingNew York, NY, US
    A tiempo completo +1
    Aon is looking for a Claims Specialist II.Do you have experience in claims adjudication and enjoy resolving issues for clients? If you'd like to grow your experience with a globally respected firm,...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    Claim Specialist - Property Field Inspection

    Claim Specialist - Property Field Inspection

    State FarmEdison, NJ, United States
    A tiempo completo
    Being good neighbors - helping people, investing in our communities, and making the world a better place - is who we are at State Farm. It is at the core of how we operate and the reason for our suc...Mostrar másÚltima actualización: hace 13 días
    Claims Setup Specialist

    Claims Setup Specialist

    Raphael and AssociatesRutherford, NJ, US
    A tiempo completo
    Quick Apply
    We are looking for a detail-oriented and organized individual to join our team as a Claims Setup Specialist.This entry-level role is focused on the initial setup of claims, ensuring all information...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    Complex Claim Specialist, Trucking

    Complex Claim Specialist, Trucking

    AmTrust FinancialNew York, NY, United States
    A tiempo completo
    Complex Claim Specialist, Trucking.The Commercial Trucking Claims Adjuster is responsible for the prompt and efficient examination, investigation and settlement or declination of insurance claims t...Mostrar másÚltima actualización: hace 25 días
    • Oferta promocionada
    • Nueva oferta
    Revenue Cycle Specialist

    Revenue Cycle Specialist

    Majestic CareQueens, NY, United States
    A tiempo completo
    Revenue Cycle Specialist (ABA Therapy).The Revenue Cycle Specialist is responsible for managing the end-to-end billing process for ABA therapy services, ensuring accurate credentialing, claims subm...Mostrar másÚltima actualización: hace 12 horas
    • Oferta promocionada
    Complex Claim Specialist, General Liability

    Complex Claim Specialist, General Liability

    AmTrust FinancialNew York, NY, United States
    A tiempo completo
    Complex Claim Specialist, General Liability.Amtrust Financial Services, a fast-growing commercial insurance company, is seeking a Complex General Liability Claims Specialist.The successful candidat...Mostrar másÚltima actualización: hace 20 días
    • Oferta promocionada
    Claims TPA Business Analyst

    Claims TPA Business Analyst

    Sompo InternationalPurchase, NY, US
    A tiempo completo
    Sompo has a unique opportunity for a Claims Tpa Business Analyst in our Claim Operations team.This role will serve as a critical liaison between business stakeholders, Third Party Administrators (T...Mostrar másÚltima actualización: hace 24 días
    • Oferta promocionada
    Project Manager

    Project Manager

    Tech ObserverStamford, CT, United States
    A tiempo completo
    No sponsorship for this role and only local candidates.We are seeking a seasoned Senior Manager, Project Management to lead and support strategic HR initiatives across North America.This project ro...Mostrar másÚltima actualización: hace 5 días
    • Oferta promocionada
    Manager, Site Safety-Production Center

    Manager, Site Safety-Production Center

    libertycokeElmsford, NY, USA
    A tiempo completo
    Working at Liberty Coca-Cola Beverages LLC is all about pursuing a career not just a job.Discover what it means to be energized by a multitude of possibilities and a dynamic team.At Liberty Coca-Co...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    E&S Claim Specialist

    E&S Claim Specialist

    AmTrust FinancialNew York, NY, United States
    A tiempo completo
    AmTrust Financial Services, a fast-growing commercial insurance company, is seeking an experienced Claims Specialist for a role in Excess and Surplus Lines (E&S) General Liability.This position can...Mostrar másÚltima actualización: hace 25 días
    • Oferta promocionada
    Claims Manager, Insurance & Risk Management

    Claims Manager, Insurance & Risk Management

    InsuranceJobs.comQueens, New York, United States
    A tiempo completo
    Claims Manager, Insurance & Risk Management.Build your career while building NYC schools!.The New York City School Construction Authority (SCA) is the organization responsible for designing and bui...Mostrar másÚltima actualización: hace más de 30 días
    • Oferta promocionada
    • Nueva oferta
    Sr. Claims Advocate, SIU

    Sr. Claims Advocate, SIU

    NYC StaffingNew York, NY, US
    A tiempo completo
    Senior Claims SIU Investigator.Uber is a technology company that is changing the way the world thinks about transportation. Whether it's heading home from work, getting a meal delivered from a favor...Mostrar másÚltima actualización: hace 15 horas