Claims Examiner

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.  JOB SUMMARY:   Responsible for the timely and accurate adjudication of all 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.   PRIMARY RESPONSIBILITIES:  Review, research and finalize provider claims within established regulatory requirements and CPHL policies. Analyze provider issues 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. Conduct claim testing for CPHL products. Review claim processing results of Delegated Vendors Provides expertise and assistance relative to provider billing and payment guidelines consistent with CPHL policies and procedures and State or CMS guidelines. Document all provider contacts; including telephonically, emails, written correspondence Trouble shoot and identify root cause of problems and participate in developing solutions Provides follow up and intervention relating to provider claim inquiries Collaborate with internal teams and departments to ensure applications are processed, contracts are executed and all providers are credentialed in a timely manner. 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. EDUCATION AND EXPERIENCE:   Education   Required: BA/BS degree in a financial field or equivalent healthcare experience     Preferred:      Type of Experience                                           Required:   3 years of claim processing experience, preferably in a Medicaid/Medicare, MLTC environment, Customer Service in health insurance product environment. Preferred:     Specific Technical Skills Required:    Use of Microsoft Access or similar query tool. Proficiency with MS applications, including but not limited to Word, Excel, Outlook, Power Point, Project Strong telephonic and customer service skills   Certifications/Licensure: Required:    n/a              Knowledge and Skills: Effective presentation skills Excellent verbal and written communication skills Must be able to participate in meetings with all levels of management within the organization Detail oriented, excellent follow up Ability to multi-task in a fast paced environment Must be service oriented, quick learner, team player Appreciation of cultural diversity and sensitivity toward target population Preferred:   SCOPE INFORMATION # Direct Reports:      n/a                      PHYSICAL REQUIREMENTS: The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.  They should not be construed as an exhaustive list of all responsibilities, duties and skills required.