Provider Service Representative Ii - Boston, United States - Commonwealth Care Alliance

Commonwealth Care Alliance

Verified Company

Boston, United States

3 weeks ago

Posted by:

Mark Lane

beBee recruiter

Description

Why This Role is Important to Us:

The Provider Services Department provides a single point of contact for questions, problem solving, andaccess to care, for providers on behalf of members of the Senior Care Options (SCO) and One Care Programs.

The Provider Services Representative II (PSR) position is responsible for providing accurate, prompt, and courteous service in response to written, electronic and telephonic inquiries from Providers, Vendors, Primary or Interdisciplinary Care Team, and Pharmacies.

The PSR II will be responsible for responding to a high volume of critical telephonic and written inquiries from medical providers that directly impact our members' care.

In addition to assist with high priority special projects on a regular basis.

Complexity:
Responsible for handling calls and added inquiries from providers at all levels of complexity

Supervision Exercised:

No, this position does not have direct reports.

What You'll Be Doing:

Essential Duties & Responsibilities:

Interface with CCA's provider departments including credentialing, PDM, Provider Relations and Contracting
Answer critical incoming phone calls from providers and respond to inquiries, concerns and questions about coverage, benefits, eligibility and authorization status
Navigate through multiple, complex systems and screens while maintaining caller engagement
Thoroughly document all critical provider related information in the appropriate screen and systems.
Submit providers' verbal requests for prior authorization and educate providers on PA review process and required documentation
Assist providers in resolving claims denials and navigate processes to understand source of denial including Claims Department Registrar, Outgoing Referrals, and Retro Authorization process
Communicate rules for Continuity of Care to provider and ensure it is applied during coverage determination inquiries
Understand and educate providers about different processing timeframes including expedited timeframe
Keep up to date on all system and compliance standards and policy changes.
Assist with timely resolution of problems or complaints by providers or provider service reps.
Assist with provider retention efforts by providing the best service experience
Review billing claims and submit Jira tickets for resolution thru PCG when necessary
Assist in network providers with provider portal registration and approvals
Provide "Provider Portal" first level IT support and troubleshoot assistance to providers
Other responsibilities, duties and administrative tasks as assigned

Working Conditions:

Standard Office Conditions.

What We're Looking For:

Required Education:

Associates degree or equivalent

Desired Education:

Bachelor's Degree preferred or relevant experience in call center and/or Medicare/Medicaid plan

Required Experience:

3+ years

Desired Experience:

5+ years

Required Knowledge, Skills & Abilities:

Must have experience providing customerfocused service/activities; experience independently problemsolving by referencing information and policies; and experience with data entry
Proficient knowledge of Microsoft Office Suite
Prior experience working in a Call Center required
Knowledge of Massachusetts' health care delivery system/services required
Prior experience working in medical setting or health care sector preferred
Experience processing, interpreting and entering data into electronic medical records required
Must have experience working in a diverse environment: as colleagues, members and providers are diverse socioeconomically, ethnically, and culturally
Must possess exceptional verbal and written communication skills, including the ability to effectively articulate intended message in situations of conflict to difficult recipients
Must be flexible and comfortable working in an environment that includes continual change for quality improvement.
Must have the ability to: develop a thorough knowledge of benefits, related payment policies, and medical terminology; work independently as well as within a team environment; prioritize work; and manage and track outstanding work and work due in the future

Desired Knowledge, Skills & Abilities:

Experience working in a Contact Center / Knowledge Center preferred
Experience working with provider service or provider relations preferred
Experience working with provider data management related systems including thus not limited to: Health Trio, Share Point, EZ-Cap/EZ Net, and Cactus preferred
Experience working with CRM and Alturista systems work queue management and case allocation preferred
Adept working with time bound process, workflows, benchmarks, goals and deadlines preferred.
Introduction to provider credentialing, contracting, and claims billing/coding preferred.
College level grammar preferred.
Experience providing peer to peer coaching preferred