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AdvantageCare Physicians (ACPNY) is a primary and specialty care practice serving half a million patients across the New York metropolitan area. Nurse Practitioners provide medical services in collaboration with a physician, for patients in primary care as well as in medical and surgical specialty a

Work closely with onsite sales colleagues to identify customers in need of enrollment services and provide post sales customer service follow-up.Interact face-to-face with customers, assisting in providing complete resolution of customer concerns including claims, benefit and enrollment inquiries th

Responsible for Quality Assurance and Testing for operations and implementations. Exceptional problem solving, analytical, interpersonal and communication skills to resolve issues within Operations (Required).

AdvantageCare Physicians (ACPNY) is a primary and specialty care practice serving half a million patients across the New York metropolitan area.With more than 30 medical offices across New York City's five boroughs and Long Island, ACPNY is continually expanding our practice and enhancing our servic

AdvantageCare Physicians (ACPNY) is a primary and specialty care practice serving half a million patients across the New York metropolitan area.With more than 30 medical offices across New York City's five boroughs and Long Island, ACPNY is continually expanding our practice and enhancing our servic

Internal Medicine or Family Medicine. Board Eligible/Board Certified in Internal Medicine or Family Medicine. We are seeking an experienced Internal or Family Medicine trained physician to join us in pursuit of high-quality patient care to provide a full scope of primary care services including but

Assist less experienced Account Executives with more complex prospect and customer issues. Generate reports to management that communicate accurate, complete and current information on account status including competitive intelligence. SME on process improvement issues for Account Management.

AdvantageCare Physicians (ACPNY) is a primary and specialty care practice serving half a million patients across the New York metropolitan area.With more than 30 medical offices across New York City's five boroughs and Long Island, ACPNY is continually expanding our practice and enhancing our servic

Assist less experienced Account Executives with more complex prospect and customer issues. Focus on client satisfaction, retention and growth collaborating effectively with other areas of EmblemHealth to proactively prevent and resolve issues as needed. SME on process improvement issues for Account

Work closely with onsite sales colleagues to identify customers in need of enrollment services and provide post salescustomer service follow-up. Provide post sales customer service follow-up with Sales colleagues, both onsite and in the field within the region, to follow up on member customer servic

Registered Pharmacist: New York State pharmacy license (Required).

Work closely with onsite sales colleagues to identify customers in need of enrollment services and provide post sales customer service follow-up. Provide post sales customer service follow-up with Sales colleagues, both onsite and in the field within the region, to follow up on member customer servi

Prepare journal entries, account reconciliations and other analyses as part of the month end close process.Ensure that the monthly close for EmblemHealth is performed timely, accurately and in accordance with Generally Accepted Accounting Principles (GAAP).Participate in the development and enhancem

This is a community based field opportunity with travel within New York City.Must reside in NY and be willing to travel 3 days per week.In support of the EmblemHealth Pharmacy Quality program focused on initiatives to meet corporate STAR goals.As part of the Comprehensive Medication Management Progr

Responsible for day-to-day operations for all activities related to contracts with minimal supervision and direction, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as communication of Plan policies and procedures. Assist provid

For Grievances and Appeals: Perform administrative functions to close out Grievance and Appeal files; rout claims for adjustment; ensure validating adjustment was made correctly in accordance with the appeal decision; follow up with other business areas to ensure resolution actions were completed &

Review project timelines, deliverables, budgets, and risks using project management tools and frameworks. Bachelor's degree in Project Management, Public Administration, Community Development, Social Sciences, or related field. Proficiency in project management tools, data analysis software (e.

Bachelor's degree in Actuarial Science, Mathematics, other physical science, or related finance/business degree required. Must make sufficient progress toward obtaining actuarial credentials, defined as sitting for a minimum of one exam per year, scoring above a zero, and obtaining at least a combin

Present to, follow up and sell Individual Medicaid, Essential Plan, QHP and CHP products on a direct sales basis.Assist and enroll individuals by completing the appropriate application forms, obtain required documentation necessary for enrollment, and meeting necessary enrollment targets.Conduct hom

Very strong customer service orientation and commitment to quality, responsibility, high work standards, and initiatives (Required). Ability to effectively manage multiple projects and tasks with competing objectives, priority levels, and deadlines; and to develop and adhere to time schedules to me

Organization/prioritization ability; and the ability to effectively manage a caseload of highly complex members. Coordinate and provide care that is safe, timely, effective, efficient and member-centered to support population health, transitions of care, and complex care management initiatives. Enga

Provide technical, administrative, and logistical support in executing community events for Marketplace Sales to facilitate the selling and engagement functions. Assist with the management of company sales events, sponsorships, and community activations. Ensure the sales department staff have a prof

Underwrite EmblemHealth's existing and new business accounts, including Broker Accounts within published time frames.Process sold new business groups.Develop and maintain good working relationships between Underwriting and Marketing.Maintain logs and complete various reports as needed.Underwrite new

Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care. Case and/or utilization management/care coordination and managed care experience. Ensure accurate administration of

Manage and nurture client relationships within EmblemHealth's employer group clients to ensure they have the information, products, and support needed from the health plan.Responsible for building and expanding existing pharmacy service contract accounts.Work with internal departments (sales, claims

Perform timely pre-payment audits of high dollar claims to verify the accuracy of claim payment and processing. Develop appropriate and cost-effective recommendations by partnering with Claims, Provider File Ops, Provider Network Mgmt. Working knowledge of insurance coding and/or claims experience.

Work closely with onsite sales colleagues to identify customers in need of enrollment services and provide post salescustomer service follow-up.Interact face-to-face with customers, assisting in providing complete resolution of customer concerns including claims, benefit and enrollment inquiries th

Perform accurate and timely intake and data entry for all UM authorization requests and referrals for all lines of business, upon receipt of inbound utilization management requests, via call, fax and web portal, in accordance with departmental policy and regulatory requirements.

As part of the overall clinical audit process, assess and audit medical record charts to ensure compliance with internal (EmblemHealth) and external regulatory and accreditation requirements.Compare collected data against Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Assuranc

Supervise and develop direct reports accountable for Medicare and State Sponsored areas, as well as other staff.

Establish and maintain active working relationships with assigned facility care managers/utilization management departments to facilitate appropriate clinical reviews and patient care. Case and/or utilization management/care coordination and managed care experience. Ensure accurate administration of

Conduct medical appropriateness evaluations of acute care hospital admissions, post-acute care requests, and selected outpatient procedures. Ensure that members are receiving the appropriate level of care in the appropriate setting for the appropriate length of time within the established guidelines

Provide support and assistance to mainstream Medicare, Medicaid, HARP, Child Health Plus and Essential members telephonically (inbound and outbound) with a variety of non-clinical healthcare and membership needs: completing health care gaps, health related assessments, and state required application

Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE. Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with NCQA, CMS, State and ot

Oversee research, development, implementation, maintenance and enhancement of technology for managed system capabilities and upgrades; interface with business clients to ensure concerns are managed. Develop and execute on a technology and process roadmap for owned systems. Champion and monitor adher

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. Identify potential/actual c

Identify data improvement opportunities through review of HEDIS/QARR/Star reports and data outputs and detecting data acquisition, capture, and system error issues. Incorporate diverse data sources across internal and external platforms to continuously improve the plan's healthcare qualitymetric per

Collaborate with Network Management and Analytics to ensure proper capture of negotiated and modeled contractual agreements. Analyze negotiated contracts to determine Network interaction with the core systems ensuring that reimbursement is in line with negotiated intent. In coordination with Network

Work with the manager to deliver and organize onsite health seminars and classes, including EH vendor-led classes. Represent EmblemHealth at onsite interactions with community partners and leaders. Work closely with onsite sales colleagues to identify customers in need of enrollment services and pro

BA/BS in Mathematics, Statistics, Economics, Healthcare or related discipline required; Master's preferred. Experience working in a healthcare setting (within a provider health system or health insurance company) preferred. Experience working with healthcare data including but not limited to claims,

Conduct complex, in-depth investigations of reported fraud involving the full range of healthcare products.Develop and maintain relationships with law enforcement (HHS-OIG, FBI, DOJ), regulatory agencies (DFS, MEDIC, OMIG, MFCU) and with industry peers.Provide guidance to the Fraud Investigators on

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Work with Neighborhood care team to maintain and improve EmblemHealth's image as a High Quality and Affordable health plan in the community. Present EmblemHealth insurance products and benefit plans to community groups, small businesses and other prospective subscribers. Function as a liaison betwee

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Provide a bridge between analytics and strategic client engagement and EmblemHealth's largest and most complex account: the City of New York. Research and utilize appropriate metrics and analytics to track performance and identify/predict potential issues that could impede EmblemHealth's ability to

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