Senior Claims Overpayment & Recovery Analyst

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com . Senior Claims Overpayment & Recovery Analyst Proactively assess and monitor vendor operational performance to ensure contractual targets and quality expectations are met. Monitor and support daily financial recovery activities to ensure negative balance claims and identified overpayments are recovered timely and appropriately. Engage directly with Special Handling, Tier 1, and high-exposure non-special handling facilities/providers across the enterprise. Identify improvement opportunities and collaborate with internal and external business partners to develop action plans that resolve issues and prevent future overpayments. Principal Accountabilities Strengthen claims recovery by building and maintaining effective partnerships with Emblem Providers and Provider Network Management to support overpayment identification, collection activity, and direct provider engagement. Monitor provider outreach/follow-up activities to ensure timely responses and resolution of identified overpayments. Investigate and analyze claim overpayments, review root cause findings with providers, and drive timely closure of outstanding overpayment balances. Analyze claims, eligibility, benefits, contracts, payment history, and reimbursement methodologies to determine recovery and negative balance opportunities. Perform research and analysis of refund root causes and initiate corrective action plans for issue resolution and future prevention. Partner cross-functionally with providers and operational areas, including Claims, Provider Network Management, Contract Configuration, Provider File Operations, and Payment Integrity, to resolve complex recovery issues, identify overpayment drivers, and support root cause remediation. Collaborate with Cognizant and IT to maximize system offset capabilities and expedite recovery of identified overpayments. Analyze overpayment data and recovery trends to recommend operational, configuration, and policy improvements that enhance payment accuracy, reduce root causes, and improve recovery performance. Monitor recovery inventory and productivity to ensure compliance with service level agreements and departmental performance goals. Investigate potential third-party liability cases, including commercial or Medicare insurance, workers’ compensation, and motor vehicle insurance referrals from Claims, Billing and Enrollment, Member Services, Provider Services, reports, and mass mailing questionnaires. Develop reports and analyze recovery metrics to support leadership decision-making and continuous process improvement. Assess and monitor vendor performance across core processes to ensure contractual requirements, SLA targets, and EmblemHealth customer experience objectives are met; analyze and present SLA performance results. Perform transactional audits and compliance, operational, and procedural reviews to evaluate vendor quality and adherence to requirements. Recommend process improvements and focused reviews to strengthen vendor performance, quality, and operational effectiveness. Participate in system testing, implementation activities, and special projects related to recovery operations and payment integrity. Qualifications Education, Training, Licenses, Certifications Bachelor's degree required; additional years of experience and/or training/certification may be considered in lieu of educational requirement Relevant Work Experience, Knowledge, Skills, and Abilities 3 – 5+ years of relevant experience in auditing and assessment activities and financial recovery in a healthcare provider environment required Experience with Medicare Secondary Payer (MSP), Coordination of Benefits (COB), provider and member recoveries, and overpayment investigations required Experience interpreting CMS regulations, provider contracts, reimbursement methodologies, and health plan benefits required Ability to independently perform research utilizing multiple sources required Demonstrated experience conducting complex claim investigations and financial analysis required Ability to discern and identify patterns/trends of issues and provide recommendations for resolution required Pharmacy Experience preferred Excellent collaboration skills and the ability to influence management decisions required Strong auditing skills that can be applied across all types of business problems required Ability to perform root cause analysis and implement continuous improvement methodologies required Ability to independently manage highly complex recovery investigations with minimal supervision required Ability to exercise sound judgment and make evidence-based decisions required Ability to identify operational risks and recommend corrective actions required Ability to build collaborative relationships across departments and with external business partners required Additional Information Requisition ID: 1000003282 Hiring Range: $56,160-$99,360 Security Disclosure If you receive a job offer from EmblemHealth, the email will be from "HRTalentAcquisition" with the subject: "Offer of Employment for (job title) – Please respond online." We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail. Pay Disclosure At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation. EEOC Statement We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law. Sponsorship Statement At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs. #J-18808-Ljbffr EmblemHealth