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  • Margate, FL, USA
    Req #474
    Friday, January 15, 2021
    JOB SUMMARY:   The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their quality of life. The Utilization Management nurse will assess and process all authorization requests to determine medical necessity to ensure all care services, member education, and preventative interventions are maintained.     PRIMARY RESPONSIBILITIES:            ... More
  • Margate, FL, USA
    Req #478
    Friday, January 15, 2021
    We're expanding our footprint and seeking Full Time LPN’s to join our Margate, Florida team. ESSENTIAL DUTIES AND RESPONSIBILITIES Implements plan of care initiated by the registered nurse. Provides accurate and timely documentation consistent with the plan of care. Assesses and provides patient and family/caregiver education and information pertinent to diagnosis and plan of care. Informs Team Lead of issues pertinent to the care plan process and any known or perce ... More
  • Staten Island, NY, USA
    Req #471
    Friday, January 15, 2021
    JOB SUMMARY:   The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their quality of life. The Utilization Management nurse will assess and process all authorization requests to determine medical necessity to ensure all care services, member education, and preventative interventions are maintained.     PRIMARY RESPONSIBILITIES:            ... More
  • Staten Island, NY, USA
    Req #466
    Thursday, January 7, 2021
    JOB SUMMARY: Under the direct supervision of the Director of Operational Compliance, Audits and Ongoing Monitoring, the Compliance Investigator is responsible for: fraud and abuse investigations and working in tandem with the Department’s Compliance Auditors in performing non-medical necessity portion of audits.  By definition the non-medical necessity portion of the audit is that section which does not require licensed clinical expertise.  Examples of non-medical necessity audits are ... More
  • Staten Island, NY, USA
    Req #470
    Thursday, January 7, 2021
    JOB SUMMARY:   Reporting to the CEO, this position will be responsible for providing strategic and legal guidance on a range of business and regulatory matters, including but not limited to; overseeing work product of outside counsel, performing health care regulatory due diligence, contract review and administration, including provider and vendor contracts/procurement, legal oversight of investigations - both internal and external, and providing legal transactional advice to Human Resources ... More
  • Staten Island, NY, USA
    Req #467
    Thursday, January 7, 2021
    JOB SUMMARY: The Home Care Relations Liaison position is responsible for working with internal departments regarding existing members request for provider change.     PRIMARY RESPONSIBILITIES:    Point person for Utilization Management, Case Management and G&A regarding resolution to members request for a change in provider Communicate with current provider regarding stabilizing services Communicate with providers regarding staffing new cases ... More
  • Margate, FL, USA
    Req #389
    Tuesday, January 5, 2021
    Come join our team of dedicated professionals. Take your career in a new direction. We are currently accepting applications for compassionate, motivated Full Time, EXPERIENCED & NEW GRADUATE REGISTERED NURSES for our CHAA division. We strive to provide QUALITY services to our patients. The RN Coordinator of Care (COC), responsible for organizing and directing home care services to patients.  Ensures appropriate coordination among all professional and paraprofessional services related to ... More
  • Staten Island, NY, USA
    Req #441
    Tuesday, January 5, 2021
    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 identifie ... More
  • Staten Island, NY, USA
    Req #439
    Tuesday, January 5, 2021
    JOB SUMMARY:  Oversees, coordinates, plans and organizes the day-to-day operations and administrative matters to support the goals and objectives of the Network Contracting Department.      PRIMARY RESPONSIBILITIES:  Draft and negotiate amendments & addendums to physician, hospital and ancillary contracts.  Assist in development of proposal for new business as it relates to the provider network. Maintains files and documentation logs for providers that are in the process of being contracted. R ... More
  • Staten Island, NY, USA
    Req #341
    Tuesday, January 5, 2021
    JOB SUMMARY:   At CENTERS PLAN FOR HEALTHY LIVING (CPHL), our market-leading Medicare Advantage benefits and aggressive marketing has seniors calling in daily to become members. Are you the right person to sign them up?   As a Phone Benefits Advisor, you have two important jobs to do: the first part of your job is to actively sell the Medicare product directly over the phone for CPHL. Can’t make the sale? CPHL has a strong team of Field Marketing Representatives who w ... More
  • Staten Island, NY, USA
    Req #424
    Tuesday, January 5, 2021
    JOB SUMMARY:   The objective is to ensure ongoing compliance, provide support and training by monitoring the field staff on a monthly basis.  The Trainer/Auditor will provide oversight of the field staff. He/she will bring back observations and recommendations for the Training & Development department to utilize in developing strategy and plans that ensure compliance and can also be used to keep class trainings relevant and up to date. The Trainer is responsible for conducting new ... More
  • Staten Island, NY, USA
    Req #408
    Tuesday, January 5, 2021
    JOB SUMMARY:   Ensure compliance with federal and state legal and regulatory requirements relative to Medicare and Medicaid Managed Care. PRIMARY RESPONSIBILITIES:   Auditing and monitoring processes in accordance with all applicable federal and state laws and regulatory requirements, including CMS guidelines governing the administration and marketing of Medicare Advantage. Represent senior management at various committees, meetings, and seminars Communicate with CMS ensure timely completi ... More
  • Staten Island, NY, USA
    Req #410
    Tuesday, January 5, 2021
    Provider Data Maintenance Operator Summary:  The Provider Data Maintenance Operator assists the Provider Data Maintenance Supervisor with any of the following: provider demographic updates, contract updates, fee schedule updates, auditing, running reports, etc. The Operator will typically be assigned as a lead on any special projects that may arise. Primary Responsibilities: The Provider Data Maintenance Operator is responsible for, but not limited to: Cre ... More
  • Jamaica, Queens, NY, USA
    Req #404
    Tuesday, January 5, 2021
    JOB SUMMARY:   The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their quality of life. The Utilization Management nurse will assess and process all authorization requests to determine medical necessity to ensure all care services, member education, and preventative interventions are maintained.     PRIMARY RESPONSIBILITIES:              Authoriza ... More
  • Staten Island, NY, USA
    Req #221
    Tuesday, January 5, 2021
    JOB SUMMARY: This position tracks and maintains members Medicaid/Medicare coverage within the various CPHL lines of business by productive communication with members, assigned vendors engaged by CPHL, state and city contacts and inter-departmental communication within CPHL to successfully sustain members appropriate coverage. PRIMARY RESPONSIBILITIES: Up-to-date knowledge of the guidelines and regulations that affect members eligibility and coverage. Effective and professiona ... More
  • Garden City, NY, USA
    Req #370
    Tuesday, January 5, 2021
    JOB SUMMARY:   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 ... More
  • Farmingdale, NY 11735, USA
    Req #279
    Tuesday, January 5, 2021
    JOB SUMMARY:  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 testi ... More
  • Staten Island, NY, USA
    Req #303
    Tuesday, January 5, 2021
    JOB SUMMARY:   Centers Plan for Healthy Living is seeking a Salesforce Business Analyst. This individual will be responsible for application support for Centers Plan for Healthy Living (CPHL) core systems (e.g., Medical Management, Claim, Data Warehouse, etc.). The Salesforce Business Analyst will help review and resolve staff issues related to applications, analyze incoming requests for system enhancements, and enhance systems to meet business needs.   PRIMARY RESPON ... More
  • Staten Island, NY, USA
    Req #284
    Tuesday, January 5, 2021
    JOB SUMMARY:   Responsible to maintain, upgrade and provide support for the software and networks of Centers Plan for Healthy Living (CPHL) core systems (e.g., Medical Management, Claim, Data Warehouse, etc.).  Review and resolve staff issues related to applications.  Analyze incoming requests for system enhancements.  Enhance systems to meet business needs.     PRIMARY RESPONSIBILITIES:    Manage system infrastructure including databases, networks, and ot ... More
  • Margate, FL, USA
    Req #319
    Tuesday, January 5, 2021
    Opportunity Summary:   Fulfills member needs and sends correspondences to ensure member satisfaction. Has knowledge of commonly-used concepts, practices, and procedures. Has knowledge of all LOBs, scripts, and workflows- or is able to obtain information rapidly as needed. Relies on instructions and pre-established guidelines to perform the functions of the job. Works under immediate supervision. Primary job functions do not typically require exercising independent judgment. Report ... More
  • Staten Island, NY, USA
    Req #266
    Tuesday, January 5, 2021
    JOB SUMMARY:   The Medicare MAP Advisor- Will promote and sale MAP and Medicare Line of Business, maintains relationships, services our existing customers and secures new customers by consultative selling/marketing and performing all required tasks assigned by the Sales Field Manager. Incumbent will be responsible for educating and enrolling potential beneficiaries by explaining program benefits in a manner that is compliant with Center for Medicare and Medicaid Services (CMS) and ... More
  • Staten Island, NY, USA
    Req #244
    Tuesday, January 5, 2021
    JOB SUMMARY:   Centers Plan for Healthy Living is seeking a Configuration Analyst. This individual will serve as the primary resource to our Claims, Provider Services and Authorizations departments. The role will aid in configuration design, analysis, testing, and documentation related to the QNXT software platform regarding, but not limited to, benefits, sponsors, contracts, and authorizations. The Configuration Analyst will coordinate various aspects of planning, development, im ... More
  • Garden City, NY, USA ● Staten Island, NY, USA
    Req #88
    Tuesday, January 5, 2021
    JOB SUMMARY:   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 ... More
  • Garden City, NY, USA ● Staten Island, NY, USA
    Req #203
    Tuesday, January 5, 2021
    JOB SUMMARY:   Responsible for the auditing functions of Centers Plan for Healthy Living (CPHL) claims. Collaborates with other Health plan departments and Management to ensure claims are processed in accordance with Federal, State and CPHL established guidelines and/or policies and procedures. Provides feedback or suggestions to enhance current processes and/or systems; works under general supervision.     PRIMARY RESPONSIBILITIES:    Conducts monthly audits of CPHL clai ... More
  • Staten Island, NY, USA
    Req #237
    Tuesday, January 5, 2021
    JOB SUMMARY The Quality Assurance Specialist (QAS) isresponsible for monitoring and assessing the quality of the performance of ourClaims Reconsideration Representatives. The QAS will monitor inbound andoutbound calls to assess representative’s demeanor, customer serviceperformance, conformity to company policies and procedures and compliance withregulatory requirements. This individual will assist in developing andimplementing call center quality processes and procedures; as well as makere ... More