Centers Plan for Healthy Living

  • Claims Auditor

    Job Locations US-NY-Staten Island
    Posted Date 11 months ago(4/25/2018 10:57 AM)
    # of Openings
  • Overview


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    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.




    • Conducts audits of CPHL claims processed internally or by Delegated Vendors utilizing CPHL guidelines, policies and procedures or any other regulatory requirements.
    • Assists in developing and maintaining frequent audit reports based on identified issues and recommendations of management.
    • Reviews internal and Delegated Vendor production reports to ensure compliance with all regulatory requirements and CPHL policies.
    • Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements.
    • Maintains documentation of changes to claim processing guidelines and where appropriate, ensures policies and procedures are created or updated.
    • Communicates and follows up either orally or in writing with a variety of internal and external sources.
    • Evaluates Prospective Payment System (PPS) (e.g. APC, DRG, etc.) grouping and pricing information.
    • Meets individual and departmental standards with regards to quality and productivity.
    • Identifies and documents claim issues resulting from audits or other internal resources.
    • Participates in audits of the Delegated Vendors and Compliance as required.
    • Provides expertise and assistance relative to provider billing and payment guidelines consistent with CPHL policies and procedures and State or CMS guidelines.
    • Performs other duties and special projects as assigned and directed.


    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.



    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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