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Job Details

Claims Pricing Examiner

Job Ref: 46318
Category: Claims
Department: CLAIMS
Location: New York, NY
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $51,648.00
Salary Range: $51,648.00 - $51,648.00

Marketing Statement

MetroPlus Health Plan 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, MetroPlus’ 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. 

Position Overview

The position is responsible for the pricing of all contracted facilities, GoldCare and Essential Plan Negotiated Payment agreement and non-contracts in regard to the processing and the adjustment of outpatient and inpatient claims; identifying and resolving operational and/or system problems specific to contracts, and MHP Core configuration set-up for the Medicaid claim type and the Essential Plan and GoldCare claim type. The position is a resource for claims, contracting, pricing and coding issues and provides analytical support for the development and implementation of all technical/operational changes relative to claims processing.

Job Description

  • Process Outpatient/inpatient claims for the Medicaid and the Essential Plan and GoldCare line of business for all contracted facilities. 
  • Evaluates, examines and adjudicate claims pended by the system due to contractual and/or payment discrepancies by reviewing description of services on claims related to outpatient and/or inpatient claims. 
  • Process high level claims inquiries about performing claims adjustments to correct payment errors (overpayment/underpayment) associated to outpatient and/or inpatient claims.
  • Research provider inquiries regarding pricing discrepancies including recommending changes for system design, methods, procedures, policies and workflows and contractual implementation.
  • Manage and ensure appropriate follow-up and closure of all inquiries.
  • Participation in the development, testing and implementation of new and or revised system enhancements to ensure effective and efficient claims processing.
  • Ensure adherence to all Claims Processing legislative and regulatory requirements.
  • Participate in quality project as required by management.
  • Perform other duties as assigned by the Claims Operation Support Specialist.

Minimum Qualifications

  • At least three (3) years of claims insurance experience.
  • A satisfactory combination of education, training and experience
  • High School Diploma or General Education degree required. 
  • Associate/Bachelor degree preferred or equivalent experience.  
  • Analytical and problem solving abilities sufficient to effectively define complex problems and solutions in a logical and organized manner.
  • Thorough knowledge of medical terminology, CPT, ICD-9, ICD-10 and Revenue Codes
  • Strong research skills required. 
  • Ability to manage multiple assignments simultaneously.
  • Basic competency in word processing, spreadsheets, and database

Professional Competencies

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  • Written/Oral Communication

How To Apply

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:


MetroPlus Health Plan
Human Resources Department
160 Water Street 8th Floor
New York, NY 10038
Attn: Recruitment Unit

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