Provider Service Representative

Job Description:

Inbound call center responsible for the proper and courteous handling of provider contacts regarding complex benefits, authorizations, claims resolution, provider enrollment, policies, national and organizational billing guidelines, and other provider concerns by directing, educating, and facilitating resolution via phone. Promoting provider use of and access to the knowledge, tools, and resources necessary to facilitate the proper application of plan member insurance coverage.
 

Essential Functions

• Receive, service, and resolve provider inquiries, questions, and complaints within all established processes and procedures via phone for Level 1 queues as assigned—including calls pertaining to eligibility, benefits, authorization, claims, pre-service and post service provider appeals, contracting and credentialing, EDI issues, or general provider assistance for Medicaid plans and Medicare plans while maintaining established individual productivity metrics. Leverage provider-specific acumen regarding review of coding and billing guidelines for common and specialty claim submissions, Medicare NCD & LCD guidelines, medical policies, familiarity with EDI claims and eligibility files, and other familiarity with provider enrollment and revenue cycle processes.
• Promote professional and courteous interactions with callers, peers, leaders, and other departments by flexing communication styles as necessary to ensure mutual understanding of concerns and actions, that positive outcomes may be achieved for providers and members within the confines of policy.
• Actively access and leverage available resources, tools, and support, including knowledge articles, medical policies, team procedures, and escalation support, necessary to provide accurate responses to provider questions and concerns.
• Document, route, manage, and otherwise follow up on inquiries in accordance with team procedures.
• Consistently observe scheduled arrival times, breaks, lunches, departures, and other scheduled events as assigned.
• Recognize, promote, and enforce appropriate provider utilization of self-service options as established by team procedures.

Qualifications

Physical Demands

• Pallet to Waist (6" from floor) > 5 lbs: Seldom up to 10 lbs
• Waist to Waist > 5 lbs: Seldom up to 10 lbs
• Waist to Chest (below shoulder) > 5 lbs: Seldom up to 10 lbs
• Waist to Overhead > 5 lbs: Seldom up to 10 lbs
• Bilateral Carry > 5 lbs: Seldom up to 10 lbs
• Unilateral Carry > 5 lbs: Seldom up to 10 lbs
• Pushing Force > 5 lbs: Seldom up to 20 lbs
• Pulling Force > 5 lbs: Seldom up to 15 lbs
• Sitting: Frequently
• Standing: Occasionally
• Walking: Occasionally
• Forward Bend - Standing: Seldom
• Forward Bend - Sitting: Occasionally
• Trunk Rotation - Standing: Seldom
• Trunk Rotation - Sitting: Occasionally
• Squat: Seldom
• Stair Climbing: Seldom
• Reach - Above Shoulder: Seldom
• Reach - at Shoulder or Below: Seldom
• Handling: Occasionally
• Forceful Grip > 5 lbs: Seldom
• Forceful Pinch > 2 lbs: Seldom
• Finger/Hand Dexterity: Frequently
• Visual Acuity ¹
  [None = No; Seldom = Yes]: Seldom

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