Centers Plan for Healthy Living

  • Claims Resolution Phone Representative

    Job Locations US-NY-Staten Island
    Posted Date 1 year ago(4/28/2017 2:54 PM)
  • 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.



    As a Claim Resolution Phone Representative, you'll be responsible to resolve provider issues and respond to inquiries with efficiency and urgency. This is an opportunity to identify and exceed our customer expectations by committing to and building strong relationships.  You'll do this every day by quickly responding to calls from health care providers to help answer questions and resolve issues regarding health care claims and payments.



    • Professionally handle incoming inquiries via telephone, email or fax from providers (i.e. physician offices, clinics, social day cares, home care agencies, DME suppliers) regarding claim decision and payments across all Centers Plan for Healthy Living (CPHL) product offerings.
    • Thoroughly and efficiently gather claim information, assess and fulfill the caller’s needs and educate the caller where applicable regarding claim submission procedures.
    • Focus on resolving issues on the first call; navigate through the appropriate computer system(s) to identify the current status of the issue. 
    • Adjust claim(s) as warranted based on discussion and review of the provider’s issue.
    • Deliver all information and questions in a positive, conversational and compassionate manner to facilitate developing a relationship with the provider, while providing the best customer service experience possible
    • Warm transfer calls to other business units for further resolution of the callers issue while adhering to CPHLs policies.
    • Complete the documentation necessary to track provider issues and facilitate the reporting of overall trends
    • Prepares correspondence, maintains phone and contact logs, and documents call details as appropriate.
    • Meet or exceed the performance goals established for the position in the areas of: efficiency, call quality, provider satisfaction, first call resolution and attendance
    • Continuously evaluate and identify opportunities to drive process improvements that positively impact providers.
    • Maintains strong knowledge of CPHL products and the applicable state and federal regulations.
    • Assist Claims Department in special projects as assigned.




    • Required: HS Diploma
    • Preferred:  2 years college




    • 1+ years of claim processing or claim resolution experience.
    • Strong Microsoft Office skills (Excel in particular) and ability to learn new programs and software
    • Demonstrated ability in using computer with strong keyboard and navigation skills
    • Ability to navigate a computer while on the phone
    • Ability to multi-task, this includes ability to understand multiple products and multiple levels of benefits within each product
    • Ability to remain focused and productive each day though tasks may be repetitive
    • Must type 45+ words per minute
    • Familiar with ICD-10, HCPCS, CPT and medical terminology
    • Strong attention to detail and excellent communication/listening skills.
    •  Demonstrated passion for excellence with respect to treating and caring for customers.
    • Ability to identify customer needs and clearly articulate product and service offerings.


    • Proficiency with MS applications, including but not limited to Word, Excel, and Outlook.



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