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Claims Review Analyst

Company: Emblem Health
Location: Melville
Posted on: May 3, 2021

Job Description:

Support contract performance management of a large health system. Review and analyze suspected underpaid and overpaid claims from hospital, ancillary, and provider groups based on contractual and industry guidelines. Identify and analyze single issues and trends to determine root causes. Provide recommendations for solutions to minimize errors and delays in systems and/or processes. Monitor system output to ensure proper functioning.


  • Evaluate disputed claims for system configuration, claims processing, and/or contractual issues to facilitate claims review.
  • Maintain and organize detailed information on claims dispute files to ensure appropriate and comprehensive data is returned to the provider timely.
  • Track issues and monitor trends to support their resolution.
  • Identify potential/actual claims problems (single or recurring/trending) and document root cause analysis; present findings to management.
  • Improve quality, enhance workflow, and provide efficiencies within departments, identify opportunities for improvements; develop and present recommendations for changes.
  • Develop and maintain detailed understanding of rates as per assigned contract.
  • Support departmental goals for cycle time by organizing and tracking claims for review.
  • Special projects as needed.


  • Bachelor's degree required; additional years of experience and/or training can be used in lieu of educational requirements
  • 2 - 3 years' prior related work experience in professional/facility claims or benefits/billing environment required
  • Strong knowledge of claim processing policies and procedures required
  • Knowledge of medical terminology, ICD/CPT coding, per diem and DRG reimbursement and EDP testing procedures required
  • Proficiency with MS Office applications (word processing, database/spreadsheet, presentation) required
  • Ability to accurately interpret information from contractual and technical perspectives required
  • Must be conscientious and detail oriented, recognizing unusual patterns and troubleshooting for operational improvement and efficiencies required
  • Strong analytical and problem-solving skills required
  • Ability to effectively work on multiple projects/tasks with competing priority levels required
  • Ability to effectively absorb and communicate information required
  • Strong Interpersonal and teamwork skills required

Additional Information

  • Requisition ID: 210J1

Keywords: Emblem Health, New Haven , Claims Review Analyst, Other , Melville, Connecticut

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