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Medical Claims Processor
5 months ago
**JOB SUMMARY**:
Responsible for the timely and accurate adjudication of all provider disputes (reconsiderations) or claims for Centers Plan for Healthy Living (CPHL) products. Reviews and resolves pended and corrected claims. Analyzes claim resubmissions to determine areas for provider education or system re-configuration. Serve as the primary point of contact for claim issues raised by Providers and internal CPHL departments. Provides feedback on department workflows and identifies opportunities for redesign. Performs claims testing to ensure that systems are designed efficiently based on the Plan's benefit structure.
**Experience**
- 3+ years of claim processing experience, preferably in a Medicaid/Medicare, MLTC environment, Customer Service in health insurance product environment.
**PRIMARY RESPONSIBILITIES**:
- Review, research and finalize a provider disputed claim within established regulatory requirements and CPHL policies.
- Analyze provider disputes and collaborate with other departments to resolve.
- Identifies and documents opportunities for provider education.
- Review provider disputes or appeals and provide a detailed analysis of findings.
- Determine through research and analysis if exceptions are to be made to business processes.
- Evaluate system configuration and identify the root cause of a dispute claim and initiate a solution
- Interpret medical decision related to disputed claims and summarize findings in a decision letter.
- Interact with levels of management within and outside of the organization to provide final status of a disputed claim.
- Provides follow up and intervention relating to provider claim inquiries
- Participates in standing meetings as necessary, including but not limited to provider relations, contracting, network development, team building.
- Performs other duties and special projects as assigned and directed.
**This is an ONSITE role working from Staten Island Office.**
**Company: Centers Plan for Healthy Living**
Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living. Individualized professional and personal growth is a primary focus at CPHL. With various teams to match the unique strengths of each individual, tiered roles to support the advancement, and with opportunities for cross-training and education, CPHL is the place for a fulfilling long-term career.
Pay: $35,000.00 - $45,000.00 per year
**Benefits**:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- Monday to Friday
Work Location: In person
