Centers Plan for Healthy Living

  • Claims Auditor - Staten Island

    Job Locations US-NY-Staten Island
    Posted Date 2 years ago(3/1/2017 11:12 AM)
    # of Openings
  • Overview

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    Centers Plan for Healthy Living (CPHL), is a Managed Care Organization servicing members with Medicare and/or Medicaid.  Our goal is to provide members and all those involved in their care with the guidance and health plan choices they need for healthy living. CPHL is committed to providing quality, coordinated health care to some of the most honored and yet still vulnerable members of our community.




    Responsible for the auditing functions of Centers Plan for Healthy Living (CPHL) claims. Collaborates with other Health plan departments and Delegated Vendors to ensure claims are processed in accordance with Federal, State and CPHL established guidelines and/or policies and procedures. Participates in compliance reviews of delegated vendor’s claims processing policies and procedures. Provides feedback or suggestions to enhance current processes and/or systems; works under general supervision.




    • Conducts monthly audits of CPHL claims utilizing CPHL guidelines, policies and procedures or any other regulatory requirements.
    • Reviews internal and Delegated Vendor production reports to ensure compliance with all regulatory requirements and CPHL policies.
    • Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements.
    • Maintains documentation of changes to claim processing guidelines and where appropriate, ensures policies and procedures are created or updated.
    • Communicates and follows up either orally or in writing with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies and other carriers on any claim related matters.
    • Evaluates Prospective Payment System (PPS) (e.g. APC, DRG, etc.) grouping and pricing information.
    • Meets individual and departmental standards with regards to quality and productivity.
    • Identifies and documents claim issues resulting from audits or other internal resources.
    • Participates in on site audits of the Delegated Vendors as required.
    • Attends meetings with providers as appropriate to assist in communicating proper billing procedures and to explain company coverage guidelines. 
    • Provides expertise and assistance relative to provider billing and payment guidelines consistent with CPHL policies and procedures and State or CMS guidelines.
    • Performs other duties and special projects as assigned and directed.


    Education and Experience:

    • Required: BA/BS degree in a financial field or equivalent healthcare experience 
    • Required:   3+ years of claim processing experience with a Medicaid/Medicare Health Plan.  
    • Preferred:   Customer Service in health insurance product environment.
    • 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

    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


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