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  • 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
  • The Bronx, NY, USA
    Req #8
    Tuesday, January 5, 2021
    JOB SUMMARY:   The nurse practitioner treats acute and chronic conditions in place while maintaining the highest level of daily function possible for CPHL members.  Scope of responsibilities include building connections with members, designated representative and the interdisciplinary care team (ICT) through assessing needs, creating individualized care plans, coordination of care to ensure smooth transitions across settings.   PRIMARY RESPONSIBILITIES:    Provide proacti ... More
  • Brooklyn, NY, USA
    Req #363
    Tuesday, January 5, 2021
    JOB SUMMARY:   The nurse practitioner treats acute and chronic conditions in place while maintaining the highest level of daily function possible for CPDL members.  Scope of responsibilities include building connections with members, designated representative and the interdisciplinary care team (ICT) through assessing needs, creating individualized care plans, coordination of care to ensure smooth transitions across settings.   PRIMARY RESPONSIBILITIES:    Provide proactiv ... More
  • Farmingdale, NY 11735, USA
    Req #400
    Tuesday, January 5, 2021
    JOB SUMMARY:   The Non-Clinical Intake Temp Clerk (in-house) is responsible for monitoring CDPAS events to ensure accurate and timely completion; outreach to MDs for new and updated MD DOH forms; confirmation of PA hires with fiscal intermediaries and other communication needed with vendors; and telephonic CDPAS education to prospects and members interested in or receiving CDPAS.     PRIMARY RESPONSIBILITIES:              Telephonic outreach to prospects and ... More
  • San Juan, Puerto Rico
    Req #449
    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 #453
    Tuesday, January 5, 2021
    DIRECTOR OF CLAIMS The Director of Claims is fully responsible for all claims related operations. PRIMARY RESPONSIBILITIES: · Develop claims operations strategies and work with system vendors, staff and management to execute the complete, timely and accurate claims processing and servicing activities in compliance with regulatory agencies and organizational expectations in a manner that strives for operational excellence. · Plan, organize, staff, and coordinate the claims ... More
  • Staten Island, NY, USA
    Req #450
    Tuesday, January 5, 2021
    JOB SUMMARY:   Responsible for supervision and oversight of the Claims Quality unit of Centers Plan for Healthy Living (CPHL) which conducts internal review and audit of key operational processes including but not limited to end to end claims processing in accordance with CPHL workflow, policies, state and federal standards.      PRIMARY RESPONSIBILITIES:    Oversee claims auditin ... More
  • Staten Island, NY, USA
    Req #333
    Tuesday, January 5, 2021
    JOB SUMMARY:   The Licensed Benefits Advisor- Medicare Sales, maintains relationships, services our existing customers and secures new customers by consultative selling/marketing and performing all required tasks assigned by the Sales 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 company policies and regulations. The ... More
  • Staten Island, NY, USA
    Req #394
    Tuesday, January 5, 2021
    JOB SUMMARY:The role of the Senior Data and Interface Analyst is to ensure the integrity and accuracy of Centers Plan for Healthy Livings data and reporting across all systems.PRIMARY RESPONSIBILITIES:·Develop integrations between both internal and external systems.·Database modeling and design of Enterprise Data Warehouse to allow for ease of reporting.·Utilize advanced querying techniques with Data Marts and Cubes.·Support encounter reporting to both New York State and CMS.·Work with users to ... More
  • Staten Island, NY, USA
    Req #176
    Tuesday, January 5, 2021
    JOB SUMMARY:   The Network Data Integrity Lead oversees the Network Data Management team, promotes problem solving, communication, excellent service, process improvement and quality control, and education/development. The position requires inter-department collaboration on projects, business development, network expansion and fortification including knowledge of contracting and credentialing.      PRIMARY RESPONSIBILITIES:    Supervise a team of Data Analysts Specialists ... More
  • Farmingdale, NY 11735, USA
    Req #454
    Tuesday, January 5, 2021
    JOB SUMMARY: The Provider Recruitment Coordinator is responsible for the recruitment, contract submission, and expansion of the CPHL Provider Network.  This is an entry level position with growth and commission opportunities.   PRIMARY RESPONSIBILITIES: Recruit, negotiate, and initiate contracting of potential Network Providers Maintain detailed, accurate records Establish and maintain strong, positive relationships with providersMaintain knowledge ... More
  • Staten Island, NY, USA
    Req #328
    Tuesday, January 5, 2021
    CPHL is a Medicare Advantage Prescription Drug plan serving Medicare eligible beneficiary in the 5 boroughs of New York City, Erie and Nassau County. Overview:   The Events and Outreach Coordinator is responsible for identifying, planning, coordinating, and implementing marketing events in the community under the direct supervision of the AVP of Medicare Sales The Events and Outreach Coordinator directly supervises the marketing events and works closely with the Field Sal ... More
  • Margate, FL, USA
    Req #463
    Wednesday, December 30, 2020
    JOB SUMMARY:       Responsible for assessing patient care needs and planning home health care services.          JOB DUTIES /KNOWLEDGE    ·    Coordinates, screens and assesses home health care needs of patients referred to Agency ·    Completes intake process within established time parameters ·    Collaborates with physicians, nurses and discharge planners to identify patient care needs and to establish the appropriate level of care for patients referred to the Agency ... More