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.
Education and Experience:
Required: BA/BS degree in a financial field or equivalent healthcare experience
Type of Experience
Required: 3+ years of claim processing experience, preferably in a Medicaid/Medicare, MLTC environment, Customer Service in health insurance product environment.