Responsible for the timely and accurate adjudication of all provider disputes (reconsiderations) or 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.
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, Project
Strong telephonic and customer service skills
Knowledge and Skills:
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.