Emblems Jobs In Remote - 22 Job Positions Available

EmblemHealth Job Posting Conduct vendor performance auditing and support maintenance of provider data integrity across core operational processes. Ensure adherence to contractual requirements, regulatory expectations, and customer experience standards through routine audits and follow-up. Contribute to

Network & Contracting EmblemHealth Review vendor trends and impact on care cost, member and provider experience. Perform Root Cause Analysis (RCA) to resolve payment integrity issues to resolution. Initiate project requests, develop or support the development

Pharmacy Product Manager Serve as dedicated strategic resource to support Pharmacy product offerings and teams: support Internal Product Leads for pharmacy components, including the City of New York Account Team and Client, Medicare Product, Exchange/Essential Plan

Pharmacy Systems Coding Subject Matter Expert Serve as pharmacy systems coding subject matter expert for Prior Authorization with a focus on medical drug claim processing, review of utilization management, PA processing, and appeals; as well as

Audit Coordination Manager Lead and coordinate all phases of external regulatory audits across Medicare Advantage, Medicare Part D, Medicaid Managed Care (including Child Health Plus), and Commercial (on and off exchange) plan products, ensuring timely and

Product Management Enable better, faster, and more confident decisions by translating complex financial, clinical, and operational data into clear insights that inform strategy, product choices, and performance management for all Commercial Business to Business lines of

Program Management Load all Professional, Facility, and Ancillary contracts across all EmblemHealth lines of business in a timely and accurate manner. Provide subject matter expertise in all areas of contract configuration, fee schedules/groupers, and rate reimbursement.

Clinical Position at EmblemHealth Perform clinical reviews within the Medical Management Operations Concurrent Review utilization management department. Ensure accurate administration of benefits, execution of clinical policy and timely access to appropriate levels of care. Principal Accountabilities:

Care Management Nurse Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members health care needs, identifying gaps in care and needed support, administering/coordinating implementation

Pharmacy Account Management Lead Lead and direct pharmacy account management for the enterprise, including managing and leading Pharmacy Account Manager(s) and Clinical Pharmacy Account Manager(s) for both pharmacy direct clients as well as shared clients with

Care Management Nurse Provide care management, as part of a multi-disciplinary care team, that includes care coordination, performing telephonic or face-to-face assessments of members health care needs, identifying gaps in care and needed support, administering/coordinating implementation

Pharmacy Benefit Plan Design Specialist Support eligibility and benefits configuration and deployment, including collaboration with pharmacy benefits manager (PBM) and Cognizant, formulary teams, for configuration. Responsible for Quality Assurance and Testing for operations and implementations. Coordinate

Clinical Operations Responsible for the execution of the non-clinical aspects of the Care Management process. Ensure information is appropriately entered in the system to effectively execute member care plans, originate authorizations, request clinical information, perform case