Sr. Claims Adjuster

Posted: 03/10/17 | SHARE:


Careers at EmblemHealth: For nine decades, EmblemHealth has been making quality health care accessible and affordable for New Yorkers, and helping to make life better in the communities we serve. Our employees are proud of that legacy and want to make health care better for everyone. Here we inspire success while helping employees build meaningful careers. We offer competitive health and welfare benefits, retirement benefits, and incentive pay plans. Join us for a rewarding experience. 


  • Evaluate medical claims that suspend within the Medical Claims System utilizing EmblemHealth’s PPO proprietary conventional coding structure. Apply all PPO  Coding & Pend desktop procedures during edit resolution.
  • Correct claims as required for settlement utilizing established policies and procedures.
  • Utilizing Claims Operation’s C-More Adjudication Guidelines portal, reference QA memorandums, training guidelines, departmental memos, PRG’s, etc. and apply business rules to claims as instructed for adjudication.
  • As necessary, manually price claims utilizing the appropriate rate files while considering the provider’s network and the beneficiary’s insurance policy. The ability to interpret contract files and apply to adjudication of pended claims.
  • As needed, access PPO’s PC Helper applications such as CWI-Viewer Application, Anesthesia Calculator, PC History Look-Up and any other helper application developed by GHI to support claims processing.
  • Perform related duties as assigned.


  • Typing ability required (25 correct wpm).
  • Minimum of (1) year experience in varied and responsible clerical work.
  • Knowledge of CMS 1500 and UB04 claims forms and data elements.
  • Knowledge of medical terminology and a working understanding of Claims Processing.
  • Knowledge of EmblemHealth’s PPO contracts preferred.
  • Ability to interpret and apply written procedures.
  • Ability to be trained to evaluate Medical claims within the Medical Claims System.
  • PC Literate.

Compensation: $18.28/PER HOUR

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, Emblemhealth may provide work visa sponsorship for certain positions.


Apply for the SR. Claims Adjuster on our website at in the Careers section. Please note that the Auto Req ID for this position is 3295BR. Once we receive their application either the recruiter or myself will be in contact with them with further instructions.

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