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  • Staten Island, NY, USA
    Req #300
    Monday, September 21, 2020
    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:    Authorization of me ... More
  • Staten Island, NY, USA
    Req #367
    Friday, September 18, 2020
    JOB SUMMARY: Responsible for the reviewing, preparing and submitting enrollment applications, adhering to CMS procedures and tracking outcomes for the Medicare plans. Must be familiar with CMS guidelines surrounding enrollment procedures, and possess knowledge and understanding of the regulatory environment under which such plans operate. PRIMARY RESPONSIBILITIES:            Review, prepare, and submit enrollments in CMS database in a timely mannerComplete assigned tasks accur ... More
  • Margate, FL, USA
    Req #252
    Thursday, September 17, 2020
    We are seeking Full Time Call Center Representatives for our recently opened office in Florida. This role provides an opportunity for someone who thrives in a logistics environment with a solid customer centric approach. Responsibilities Respond to inquiries and requests via telephone and email in a timely fashion Document inquiries, requests, resolutions, and follow-up tasks Escalate inquires and requests to appropriate channels where applicable ... More
  • Margate, FL, USA
    Req #375
    Wednesday, September 16, 2020
    SUMMARY:   Assesses, formulates plans and provides assistance to members and their families in conjunction with the interdisciplinary team. Provides social services support to the member and/or caregiver as identified.  Provides support to members who are transitioning from an acute care facility back to the community.  Provides support to other departments in day-to-day care management activities as needed.     DUTIES AND RESPONSIBILITIES:   Assess individuals with men ... More
  • Farmingdale, NY 11735, USA
    Req #279
    Friday, September 11, 2020
    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, September 8, 2020
    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, September 8, 2020
    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, September 8, 2020
    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, September 8, 2020
    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, September 8, 2020
    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
  • Staten Island, NY, USA
    Req #299
    Tuesday, September 8, 2020
    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: Creation and maintenance of all provider records wi ... More
  • Staten Island, NY, USA
    Req #55
    Tuesday, September 8, 2020
    Meets sales and sales development goals as assigned by management, while ensuring full compliance with state and federal regulatory requirements Submits referrals in a complete and timely manner.  Plan, organize and execute marketing and sales programs. Develops and maintains new contacts and/or partnerships in the community,coordinates and implements strategies and growing membership, presentations,community and provider marketing events and conducts social servic ... More
  • Staten Island, NY, USA
    Req #85
    Tuesday, September 8, 2020
    JOB SUMMARY:   The Nurse Practitioner is responsible for conducting bi-annual home visits to complete health assessments on health plan members. The assessment will cover a full medical history and medication review. The assessment will also capture a comprehensive picture of the member’s health status including cognitive abilities, ADL and IADL performance as well as medical diagnoses.       PRIMARY RESPONSIBILITIES:   Perform community-based health assessments on Me ... More
  • Staten Island, NY, USA
    Req #142
    Tuesday, September 8, 2020
    JOB SUMMARY:   The Director of Complex Care oversees Medicare and Medicaid-Medicare programs including Medicaid Advantage Plus (MAP), Fully Integrated Duals Advantage (FIDA), Medicare Advantage Prescription Drug plan (MAPD), Dual Eligible Special Needs Plans (D-SNP). The Director of Complex Care will be responsible for ensuring appropriate Care Management operations by overseeing a team consisting of Clinical Team Manager, Care Managers, Social Workers and Care Coordinators.  This role a ... More
  • Garden City, NY, USA; Staten Island, NY, USA
    Req #88
    Tuesday, September 8, 2020
    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, September 8, 2020
    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, September 8, 2020
    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
  • Staten Island, NY, USA
    Req #124
    Tuesday, September 8, 2020
    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 oppor ... More
  • Staten Island, NY, USA
    Req #328
    Tuesday, September 8, 2020
    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
  • Staten Island, NY, USA
    Req #339
    Tuesday, September 8, 2020
    JOB SUMMARY:   The HEDIS Specialist is responsible for supporting the overall direction, coordination and implementation of HEDIS for Centers Plan for Healthy Living (CPHL) under the direction of the Director of Quality Management. Responsibilities include, but are not limited to developing and analyzing quality reports, analysis of quality data, coordination of outreach efforts to secure clinical documentation from Providers and providing support to the Quality Committees and cli ... More
  • Staten Island, NY, USA
    Req #333
    Tuesday, September 8, 2020
    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 Licensed B ... More
  • Staten Island, NY, USA
    Req #274
    Tuesday, September 8, 2020
    JOB SUMMARY   The Claims Trainer is responsible for planning, developing and delivering training programs that meet specific needs for the Claims Department. The trainer will collaborate with the claims management team to identify and analyze learning gaps and opportunities to facilitate staff development and promote continued high performance.     PRIMARY RESPONSIBILITIES Designs, develops, and implements training programs, material and curriculum that identify lear ... More
  • The Bronx, NY, USA
    Req #8
    Tuesday, September 8, 2020
    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
  • Staten Island, NY, USA
    Req #338
    Tuesday, September 8, 2020
    JOB SUMMARY: The Billing Analyst will be responsible for processing and reviewing Medicaid premium billing and rebilling, monitoring receivables on open billings, and managing denied billings with other departments and payors. The analyst will conduct regular reviews of prior billings to capture necessary billing refunds and write offs. Periodically, the responsibility will include research on billing records selected for compliance review. The analyst will facilitate the Finance depa ... More
  • Staten Island, NY, USA
    Req #341
    Tuesday, September 8, 2020
    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