Centers Plan for Healthy Living

Claims Manager

US-NY-Staten Island
3 months ago
# of Openings


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Responsible for managing and overseeing the overall operations of the Claims Processing unit of Centers Plan for Healthy Living in accordance with Centers Plan for Healthy Living (CPHL) 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 CPHL 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.
  • Provides training on claims processing to staff as needed.
  • Maintains a working knowledge of all Medicare and Medicaid coverage issues as they relate to CPHL 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.
  • Participates in special projects and perform other duties, as assigned.


Education and Experience:




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



Type of Experience  


Required:  Minimum five years’ experience in business/managed care setting, including three years in Medicare and Medicaid claims required. Minimum three years supervisory experience required.


Specific Technical Skills


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.


Preferred: Desired knowledge of creating queries using Access data bases or other SQL based products.



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



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.


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