Claims Service Representative

Centers Plan for Healthy Living; New York (NY); On-site; USD 52,000 - 60,000; Full time

Job summary

Cent ers Plan for Healthy Living (CPHL) is seeking an experienced provider relations/phone support specialist in New York. You will handle inquiries from physicians, clinics, and day cares regarding claim decisions and payments, educate callers on submission procedures, and work toward resolution on the first call.

You will document interactions, maintain logs, and contribute to process improvements while upholding CPHL policies and regulatory knowledge.

Qualifications

• HS Diploma required; 2 years of college preferred.
• Experience handling provider inquiries via phone, email or fax.
• Strong communication and problem‑solving abilities.

Responsibilities

• Handle inquiries from providers about claims and payments across CPHL products.
• Gather claim information, educate callers on submission procedures and resolve issues.
• Aim for first-call resolution and document call details and outcomes.
• Support quality and efficiency goals and maintain up‑to‑date product knowledge.

Skills

Customer service

Call handling

Provider relations

Communication skills

Education

HS Diploma

2 years of college preferred

Job description

Individualized professional and personal growth is a primary focus at CPHL. With various teams to match the unique strengths of each individual, tiered roles to support the advancement, and with opportunities for cross‑training and education, CPHL is the place for a fulfilling long‑term career.

Position Details:

• Professionally handle incoming inquiries via telephone, email or fax from providers (i.e. physician offices, clinics, social day cares, home care agencies, DME suppliers) regarding claim decision and payments across all Centers Plan for Healthy Living (CPHL) product offerings.
• Thoroughly and efficiently gather claim information, assess and fulfill the caller’s needs and educate the caller where applicable regarding claim submission procedures.
• Focus on resolving issues on the first call; navigate through the appropriate computer system(s) to identify the current status of the issue.
• Adjust claim(s) as warranted based on discussion and review of the provider’s issue.
• Deliver all information and questions in a positive, conversational and compassionate manner to facilitate developing a relationship with the provider, while providing the best customer service experience possible
• Warm transfer calls to other business units for further resolution of the callers issue while adhering to CPHLs policies.
• Complete the documentation necessary to track provider issues and facilitate the reporting of overall trends
• Prepares correspondence, maintains phone and contact logs, and documents call details as appropriate.
• Meet or exceed the performance goals established for the position in the areas of: efficiency, call quality, provider satisfaction, first call resolution and attendance
• Continuously evaluate and identify opportunities to drive process improvements that positively impact providers.
• Maintains strong knowledge of CPHL products and the applicable state and federal regulations.

Education and Experience:

• HS Diploma
• 2 years of college preferred

About us:

Centers Plan for Healthy Living (CPHL), is a Managed Care Organization servicing members with Medicare and/or Medicaid. Our goal is to provide members and all those involved in their care with the guidance and health plan choices they need for healthy living. CPHL is committed to providing quality, coordinated health care to some of the most honored and yet still vulnerable members of our community.

Centers Plan for Healthy Living (CPHL) appreciates its team members and all that they bring to the table. We prize collaboration and mutual respect, have high ethical and moral standards, and always seek to provide the highest level of customer care to all of our customers (members, providers, vendors and fellow team members). If you’re looking for a growing company that will listen to what you have to say, and provide you with opportunities to affect change, CPHL is the place for you!