<p>Summary of Position</p> <ul> <li>Perform high dollar claim audits and provide oversight and guidance to claim analysts. </li><li>Determine the root cause of errors and recommend appropriate corrective actions to prevent re-occurrence of these errors. </li><li>Support business initiatives with quantitative transactional analysis and sample audits. </li><li>Support business leaders with business improvement and integration projects. </li></ul> <p>Roles & Responsibilities</p> <ul> <li>Perform timely pre-payment audits of high dollar claims to verify the accuracy of claim payment and processing. </li><li>Perform cycle time analysis to determine root cause and corrective actions. </li><li>Perform comprehensive audits of adjustment transactions to verify that inquiries from groups, providers and members are resolved accurately and timely. </li><li>Conduct special audits as directed by leadership. </li><li>Provide problem definition/analysis support to the business leaders and their associated process improvements projects. </li><li>Review and evaluate management responses and corrective action plans related to audit error findings. </li><li>Work with leadership on disputed audit findings and make recommendations for corrective actions. </li><li>Develop appropriate and cost-effective recommendations by partnering with Claims, Provider File Ops, Provider Network Mgmt., Utilization Mgmt. and IT to identify any required system logic modifications related to audit findings. </li><li>Perform comprehensive reviews of new product or system implementations as requested by leadership. </li><li>Participate in the external audit process by responding to specific audit issues or questions as directed. </li><li>Make recommendations and modifications to the audit program desk level procedures (DLP's) based on changing business environment. </li><li>Perform other duties as assigned, directed, or required. </li></ul> <p>Qualifications</p> <ul> <li>Bachelor's degree </li><li>3 - 5+ years relevant work experience, preferably in auditing and improving operational processes </li><li>Additional years of experience and/or specialized training may be considered in lieu of educational requirements </li><li>Extensive experience in quality and/or root cause analysis </li><li>Working knowledge of insurance coding and/or claims experience </li><li>Knowledge of Emblem Health's processes and FACETS system </li><li>Detail oriented; strong problem identifying and solving skills </li><li>Strong communication skills (verbal, written, presentation, interpersonal) </li><li>Advanced PC literacy with emphasis on Cognos, MS Excel and MS Access </li></ul> <p>Additional Information</p> <ul> <li>Requisition ID: 1000003031 </li><li>Hiring Range: $56,160-$99,360 </li></ul>