Responsible for assisting in 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. Assists in and/or participates in compliance reviews of Delegated Vendor’s claims processing policies and procedures. Provides feedback or suggestions to enhance current processes and/or systems
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 with a Medicaid/Medicare Health Plan.
Preferred: Customer Service in health insurance product environment.
Specific Technical Skills
Required: Use of Microsoft Access or similar query tool. Proficiency with MS applications, including but not limited to Word, Excel, Outlook, Power Point.
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
· 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
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.