Claims Representative

Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The Claims Representative shall assume full responsibility and ownership for all aspects regarding claims adjudication and adjustments. In addition, the incumbent will utilize and interpret Claims Operations Policies and Procedures, coding methodologies, Plan contract language, riders, and schedules in order to accurately adjudicate claims. The incumbent will work closely with all departments such as Member Services, Claims Operations, Provider Relations, Health Care Network Strategy, Configuration and Membership and Billing to resolve provider inquiries as defined within Claims Operations procedures. The Claims Representative is required to handle multiple product lines while successfully applying problem solving and time management methodology, balancing multiple tasks as business needs arise while maintaining production and quality standards and adhering to prompt pay regulations. The specialist will address and resolve service-related issues including claim adjustment requests, appeals and complaints, eligibility determination and other claims related issues for all product lines based on specified guidelines and timeframes while advising the customer of their rights and responsibilities. The specialist will also respond to inquiries received via written correspondence.

QUALIFICATIONS :

• High school diploma or GED required.
• Minimum of one (1) year experience in health care claims review and adjudication to payment / denial utilizing CPT-4, ICD 10 and HCPCS coding preferred.
• Strong product experience is preferred, including but not limited to HMO, PPO, EPO, HDPPO, POS, Self-insured and Government Programs.
• Customer relations with additional experience in provider billing practices is preferred. Strong PC skills and Microsoft Windows and working knowledge with on-line claims processing and procedural review highly preferred.
• Experience with a documentation system to track inquiries generated and received preferred.
• Demonstrated ability to determine, analyze and solve problems related to benefits, claims appeals, claims pricing / processing by utilizing all applicable databases to make determinations is required. Demonstrated ability to successfully apply problem solving and time management methodology, balance multiple tasks as business needs arise while maintaining production and quality standards is required.
• Ability to interpret contract language related to all CDPHP's health plans to include riders and schedules to make eligibility determinations and verifications based on State statutes relating to healthcare administration and corporate guidelines.
• Demonstrated ability to effectively communicate verbally and produce business correspondence and written documents, which exhibit appropriate grammar, spelling, punctuation and sentence structure, is required.
• Demonstrated ability to maintain a positive professional demeanor. Ability to think creatively and participate in process improvement discussions as needed.

CDPHP salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. In addition to cash compensation, CDPHP employees may be eligible for an incentive payment, a discretionary cash reward based on employee and company performance. Some roles may also be eligible for overtime pay.

CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at

As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.

CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.