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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 managing and overseeing the overall operations of the Claims Processing unit of HEALTH PLAN  in accordance with HEALTH PLAN  policies, state and federal standards.  Manages the day-to-day activities of the Claims Processing staff. 

• Manages staff to ensure claims are processed accurately, within regulatory timeframes and individual performance goals while adhering to department, industry and productivity standards.  Schedules daily work assignments and assists staff in the solution of problem claims. 
• Develops indicators, monitoring tools and reporting mechanisms to support all areas of the claims department. Reviews and analyzes weekly and monthly department performance reports.  Escalates department performance issues and recommends or implements needed interventions.
• Handles escalated claim related complaints. Communicates with the appropriate parties to obtain and impart invoice data to resolve problem claims. Researches and reviews all invoice payment discrepancies to determine source of errors.
• Supports claims processing by developing and analyzing data, implementing quality improvement measures, interfacing with Finance and other HEALTH PLAN  departments, and performing other related functions as needed.
• Communicates with providers regarding unpaid claims and billing procedures. Collaborates with Provider Relations to educate providers regarding common claim issues and to resolve particular claim-related provider issues.
• Interfaces with Claim System Vendor/BPO to research problem claims, clarify procedures and to identify any problem trends.  Assists Director in monitoring BPO and related activities pertaining to BPO claims processes, configuration and claims operations.
• Develops workflows, policies and procedures for the claims department and understands how they relate to other programmatic policy and procedures.
• Acts as a liaison between the claims department, providers and other internal departments.
• Manages the maintenance of claims records and adherence to regulatory standards.
• Provides training on claims processing to staff as needed.
• Maintains a working knowledge of all Medicare and Medicaid coverage issues as they relate to HEALTH PLAN  lines of business including Managed Long Term Care (MLTC-Medicaid) and) Medicare Advantage.
• Performs all duties inherent in a managerial role.  Ensures effective staff training, evaluates staff performance, provides input for the development of the departmental budget and hires/promotes/terminates staff and recommends salary actions, as appropriate.

Competencies

• Accountable/Results-Oriented
• Adaptability/Flexibility
• Business Acumen
• Communications (written and oral)
• Customer Focus
• Initiative/Innovation
• Interpersonal Effectiveness
• Problem Solving
• Teamwork and Collaboration
• Building a Diverse/High Performing Team
• Change Management
• Project Management
• Strategic Management

Education:  Bachelor's Degree in Business Administration or related field required. 

Experience:  Minimum three to five years’ experience in business/managed care setting, including three years in Medicare and Medicaid claims required.  Minimum three years supervisory experience required.  Proficiency in a claims processing system required.  Proficient PC skills, including Microsoft Office Products such as Excel, Access, Word and PowerPoint required. Proficient use of Microsoft Access. Desired knowledge of creating queries using Access data bases or other SQL based products.