Sr. Claims Project Specialist
EmblemHealthNew York, NY, United States7 hours ago
Job type
- Full-time
Job descriptionServe 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. 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
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
Qualifications
Additional Information
Requisition ID : 1000002775
Hiring Range : $68,040-$118,800
Create a job alert for this search
Sr Project Specialist • New York, NY, United States
Related jobs
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 ...Show moreLast updated: 30+ days ago
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...Show moreLast updated: 30+ days ago
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...Show moreLast updated: 2 days ago
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...Show moreLast updated: 1 day ago
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...Show moreLast updated: 30+ days ago
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,...Show moreLast updated: 30+ days ago
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...Show moreLast updated: 30+ days ago 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...Show moreLast updated: 25 days ago 
The Senior Claim Specialist, under the direction of a Claims Supervisor, investigates and settles Property claims promptly, equitably and within established best practices guidelines in the New Yor...Show moreLast updated: 30+ days ago
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...Show moreLast updated: 7 hours ago 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...Show moreLast updated: 20 days ago 
Founded in 1923, the firm adapts a century of experience to the dynamic infrastructure needs of today.H&M leverages the collective strength of its diverse disciplines to create seamless integration...Show moreLast updated: 3 days ago
Colonial Surety Company is an insurance company licensed for business in every state, listed by the U.Treasury as an approved surety, and rated "A" Excellent by A.Our distinct, digital pr...Show moreLast updated: 30+ days ago
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...Show moreLast updated: 30+ days ago 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...Show moreLast updated: 24 days ago 
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...Show moreLast updated: 4 days ago
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...Show moreLast updated: 30+ days ago
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...Show moreLast updated: 10 hours ago
- Promoted
Sr. Claims Specialist
W.R. BerkleyJersey City, NJ, USFull-time
- Promoted
Construction Defect Claims Specialist
AmTrust FinancialNew York, NY, United StatesFull-time
- Promoted
MRSGM NA Claims Resolution Specialist, Cyber
Munich RENew York, NY, United StatesFull-time
- Promoted
Claims Specialist
Metro Public AdjustmentWayne, NJ, USFull-time +1
- Promoted
Side Hustle Project Lead
Finance BuzzFords, New Jersey, USFull-time +1
- Promoted
Claims Specialist II
NY StaffingNew York, NY, USFull-time +1
Claims Setup Specialist
Raphael and AssociatesRutherford, NJ, USFull-time
Quick Apply
- Promoted
Complex Claim Specialist, Trucking
AmTrust FinancialNew York, NY, United StatesFull-time
- Promoted
Field Property Senior Claim Specialist
ChubbNew York, NY, USFull-time
- Promoted
- New!
Revenue Cycle Specialist
Majestic CareQueens, NY, United StatesFull-time
- Promoted
Complex Claim Specialist, General Liability
AmTrust FinancialNew York, NY, United StatesFull-time
- Promoted
Associate Project Manager
Henkels & McCoy, Inc.Livingston, NJ, United StatesFull-time
- Promoted
Project Manager
Colonial Surety CompanyWoodcliff Lake, NJ, USFull-time
- Promoted
Manager, Site Safety-Production Center
libertycokeElmsford, NY, USAFull-time
- Promoted
E&S Claim Specialist
AmTrust FinancialNew York, NY, United StatesFull-time
- Promoted
Project Manager
Tech ObserverStamford, CT, USFull-time
- Promoted
Claims Manager, Insurance & Risk Management
InsuranceJobs.comQueens, New York, United StatesFull-time
- Promoted
- New!
Sr. Claims Advocate, SIU
NYC StaffingNew York, NY, USFull-time