Claims Analyst

Empower. Unite. Care.MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege.

If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + HospitalsMetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc.

As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics.

For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Responsible for investigating and resolving high level claims-related issues and possess deep understanding an various reimbursement methodologies.

Job DescriptionImproves the level of engagement between the Plan and Hospital Network, Ancillary and Community providers by providing timely resolution of issues and providing outstanding customer service and supportDetailed understanding of various reimbursement methodologies (i.

e., skilled nursing facilities, medical group, post-acute bundles, etc.,)Conducts audits to review accuracy of cost reports and payment of claimsReviews inquiries from providers regarding cost report settlementsResearches and analyzes claim processing outcomes, identifies issues and reports as necessary, and proactively outreaches to peers, supervisor, and / or providers upon findingsPrepares and analyzes cost / business proposals and reports of findings;

makes recommendations to managementApplies knowledge of established procedures to research and resolve escalated customer questions or management requestsActs as the initial contact for escalated issues from the support staff and escalates only the most complex issues to the immediate supervisorLiases between Finance, Network Operations, claims, UM, Provider Maintenance, Core and Contracting departments to resolve ongoing issues and determines root cause and ultimately, resolution of issuesReviews system setup to determine if it reflects contract language and outreaches to the Contracting Department for assistanceAttend Joint Operating Committee meetings and takes ownership of resolving issues with assigned hospitals, etc.

Contributes to development of policies and procedures, process improvement initiativesPerforms other support activities and duties as assignedMinimum QualificationsRequires a Bachelor’s degree3-5 years experience in a managed care government program claims processing / analyzing experience, working with providers in addressing reimbursement issuesOr an Associate Degree with 5-7 years or more experience in a managed care government program claims processing / analyzing experience, working with providers in addressing reimbursement issuesAbility to work independently to meet deadlinesWorking knowledge of and proficiency with Windows-based PC systems and Microsoft Word, Outlook, Excel, and PowerPoint, SharepointAbility to exercise tact and diplomacy and demonstrate strong customer service skillsAbility to prepare written and oral reports and make effective presentationsAbility to independently manage assigned workload, make decisions related to area of functional responsibility, and recognize issues requiring escalationHighly organized, detail oriented, dependable and professional individualAbility to travel to meet with Providers and their representativesProfessional CompetenciesIntegrity and TrustCustomer FocusFunctional / Technical skillsWritten / Oral Communication#LI-HYBRID