Provider Relations Representative I​/Req

Hybrid:
Applicants must be a California resident as of their first day of employment

PRINCIPAL RESPONSIBILITIES

Under the general supervision from the Supervisor, Provider Relations Call Center, the Provider Relations Representative I performs a variety of routine and semi‑routine tasks requiring a thorough knowledge of organizational policies and procedures. This position will provide administrative and operational support for the Provider Services Department. PR I staff who demonstrate proficiency in meeting, maintaining and exceeding principal performance objectives and metrics may be eligible to be promoted to a Provider Relations II role once they have worked as a PR I for a minimum of 12 months in order to be proficient with program and system knowledge in addition to meeting performance matrix requirements.

• Answer incoming provider calls, emails, and other requests for assistance in a timely manner in accordance to departmental performance targets and provide excellent customer service
• Assist providers with basic inquiries about claims, authorizations, benefits, and other issues. This includes working in conjunction with the Medical Services, Member Services, Provider Dispute Resolution Unit and Claims departments.
• Properly document all calls/contacts as required by department standards.
• Participate in regularly scheduled department meetings and trainings.
• Escalate complex issues per departmental standards.
• Follow through with solutions in an accurate and timely manner.
• Effectively maintain the Provider Portal Access and issue resolution processes.
• Effectively handle the departmental inbox and voicemail inboxes
• Maintain files, keep records, prepare schedules, compile reports, and process documents of a routine nature in an accurate and timely fashion.
• Make outgoing calls to providers as directed by other departmental needs and initiatives.
• Adopt and understand changes in benefits, workflow processes, and systems.
• Work in a cooperative manner with other departments.
• Support continuous improvement of provider relations effectiveness through the development, evaluation, and refinement of policies and procedures that meet the operational and regulatory goals and requirements.
• Maintain strict confidentiality of all sensitive information and issues.
• Participate in provider projects if needed.
• Coordinate processing of incoming and outgoing mail.
• Assist with the maintenance of data within various databases.
• Print and distribute information on request.
• Participate in the Provider Services departmental projects and meetings, as needed.
• Assist with other duties and special projects as needed.

• Answer incoming calls, emails, and other requests for assistance in a timely manner in accordance to departmental performance targets and provide excellent customer service while doing so.
• Provide accurate health plan benefits, plan rules, claim reimbursement amounts, and rules, and validate provider data on file. In addition, provide clarification on how the plan operates.
• Conflict resolution:
  Resolve provider problem/conflicts by meeting with other departmental staff as needed.
• Provider communications:
  Create and/or mail appropriate provider materials and communications as needed.
• Meetings:
  Participate in departmental and non‑departmental meetings and other scenarios.
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

• Constant and close visual work at desk or on a computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Constant use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.

Number of Employees Supervised: 0

• Two years of college or equivalent work experience.

• Minimum one year direct provider service…