Claims Reconsideration Analyst - Staten Island, United States - Centers Plan for Healthy Living

Centers Plan for Healthy Living
Centers Plan for Healthy Living
Verified Company
Staten Island, United States

4 weeks ago

Mark Lane

Posted by:

Mark Lane

beBee recruiter
Description

Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.


JOB SUMMARY:


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.


PRIMARY RESPONSIBILITIES:


  • Review, research and finalize a provider disputed claim within established regulatory requirements and CPHL policies.
  • Analyze provider disputes and collaborate with other departments to resolve.
  • Identifies and documents opportunities for provider education.
  • Review provider disputes or appeals and provide a detailed analysis of findings.
  • Determine through research and analysis if exceptions are to be made to business processes.
  • Evaluate system configuration and identify the root cause of a dispute claim and initiate a solution
  • Interpret medical decision related to disputed claims and summarize findings in a decision letter.
  • Interact with levels of management within and outside of the organization to provide final status of a disputed claim.
  • Provides follow up and intervention relating to provider claim inquiries
  • Participates in standing meetings as necessary, including but not limited to provider relations, contracting, network development, team building.
  • Performs other duties and special projects as assigned and directed.

EDUCATION AND EXPERIENCE:

Education


Required:
BA/BS degree in a financial field or equivalent healthcare experience


Preferred:

Type of Experience

Required: 3+ years of claim processing experience, preferably in a Medicaid/Medicare, MLTC environment, Customer Service in health insurance product environment.


Preferred:

Specific Technical Skills
Strong telephonic and customer service skills


Certifications/Licensure:


Required:
N/A


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 multitask 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.


Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business.

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.

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