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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.

ESSENTIAL DUTIES & RESPONSIBILITIES

Level I

+ Effectively interprets and researches Member / Provider Appeals, Grievances and/or Complaints as assigned.

+ Responsible for gathering all necessary information on file related to specific case type (Corporate Medical policies, medical records, contracts, InterQual, LCD/NCD, SSA etc.) and evaluates if additional information is necessary prior to routing for review or making decision.

+ Provides written and / or oral responses to all cases utilizing the appropriate letter templates and ensuring that the decision is communicated clearly and at the appropriate reading level.

+ Evaluates and independently manages inventory and proactively escalates any concerns to management to ensure department and regulatory requirements and timeliness measures are met.

+ Documents research steps taken for cases within the Pega platform in a timely manner to ensure data integrity and decisions to support potential legal proceedings.

+ Attends all staff meetings, completes all necessary mandatory trainings, and participates in regular developmental activities.

+ Compiles and provides Independent Review Entity (IRE) case files to external reviewer and member (upon request) if required for the line of business.

+ Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.

+ Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

+ Regular and reliable attendance is expected and required.

+ Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

+ Responsible for handling Appeals and Grievances for the Dual SNP product if assigned.

+ Responsible for handling of Level 2 Grievance and Appeal casework (CAU) or handling multiple case types with various completion timeframes (MAU).

+ Provides coverage / backup for both scheduled and unscheduled absences for Level I associates.

+ Initiates process improvements identified through daily casework that results in streamlining procedures and reduces regulatory risks to the Organization

Level III (in addition to Level II Accountabilities)

+ Responsible for handling Discrimination complaints for all lines of business.

+ Provides coverage / backup for both scheduled and unscheduled absences for Level I and Level II associates.

+ Attends Administrative Law Judge (ALJ) hearings independently without support of leadership (MAU only).

+ Provides guidance and mentoring to the less experienced team members in the absence of management. Acts as a resource for the department and a trusted advisor to the organization.

+ Shares acquired knowledge and expertise to help others learn and grow.

+ Supports department and corporate projects as assigned by management.

+ Requires minimal direct management oversight.

+ Assists with preparing external audit files as assigned by management

Qualifications:

+ Five (5) or more years in health insurance or health care delivery or an Associate degree in related area with a minimum of two (2) years related experience in Customer Service, Claims or Medical Management area.

+ Knowledge of claims processing systems preferred.

+ Exceptional verbal and written communication skills and ability to collaborate across the organization.

+ Must demonstrate exceptional organizational and time management skills and ability to work independently.

+ Must be familiar with and maintain knowledge on all State / Federal laws and regulations that affect our customers and /or their contracts.

+ Familiar with government regulations including but not limited to Managed Care Law, UR Law, DOL / ERISA legislation and Health Care Reform preferred.

+ Ability to demonstrate an understanding at a detailed level claims processing, utilization review processes and procedures.

+ General knowledge of insurance policies, procedures, rules, plus federal and state activities as they are related to members rights

+ Must be able to follow up on customer inquiries promptly and accurately. Act with a sense of urgency (importance, purpose, and drive).

+ Demonstrated experience in taking ownership of issues and follow through to resolve them.

+ Willingly adapts to effect change efficiently and smoothly.

Level II (in addition to Level I Qualifications)

+ Seven (7) or more years in health insurance or health care delivery or an Associate degree in related area with a minimum of four (4) years related experience in Advocacy, Customer Service, Claims or Medical Management area.

+ Advanced knowledge of claims processing systems and products required.

+ Demonstrated ability to handle multiple assignments and remain composed under pressure.

+ Strong knowledge of insurance policies, procedures, rules, plus federal and state activities as they are related to members rights required.

+ In depth knowledge of government regulations including but not limited to Managed Care Law, UR Law, DOL / ERISA legislation, and Health Care Reform required.

Level III (in addition to Level II Qualifications)

+ Eight (8) or more years in health insurance or health care delivery or an Associate degree in related area with a minimum of five (5) years

+ related experience in Advocacy, Customer Service, Claims or Medical Management area.

+ Demonstrated abilities in handling the highest level of complex casework and exercises decision-making in project work groups.

+ Ability to provide peer review, mentoring and support training as necessary.

+ Advanced knowledge and solid understanding of Insurance Laws and Government Regulations.

+ Expert knowledge of insurance policies, procedures, rules, plus federal and state activities as they are related to members rights required.

Working Requirements:

+ Ability to work in a home office for continuous periods of time for business continuity.

+ Ability to travel across the Health Plan service region for meetings and/or trainings 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 https://www.cdphp.com/about-us/jobs/benefits .

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.