Job Description

SUMMARY

The Provider Services Representative role is primarily responsible for receiving incoming calls from both in-network and out-of-network providers and assisting them with their inquiries. Additionally, in times of high-call volume, Provider Services Representatives will be expected to assist the Leon Health Member Services line with the handling of member calls.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Professionally handles a high volume of inbound complex calls originating from the Leon Health Provider Services line, and at times, from the Leon Health Member Services line.
  • Assists with the processing of inbound correspondence from providers received via physical mail, fax, or e-mail.
  • Assists providers with authorization, claims and payment inquiries, including, but not limited to, providing claim status, claims/authorization denial rationale, payment status, assistance with EOPs/RAs, billing information, provider portal access, etc.
  • Assists members with effectively using their health care coverage by, including, but not limited, providing Plan eligibility information, reviewing Plan rules, benefit inquiries, authorization and claims status, and addressing any complaints or issues the member is having in accessing healthcare.
  • Identifies provider complaints (disputes/appeals) and ensures the provider is either educated or their complaint is routed to the appropriate department for resolution.
  • Identifies member complaints (grievances/coverage requests/appeals) and ensures these requests are properly classified, addressed, and routed for further review and resolution if needed.
  • Contributes to meeting or exceeding Leon Health Provider Services call center metrics and goals.
  • Follows up with callers to provide response or resolution steps as needed.
  • Clearly documents incoming and outgoing call reasons and dispositions in the call center system.
  • Develops and maintains positive provider and member relations and coordinates with various functions within the company to ensure provider and member requests and inquiries are handled appropriately and in a timely manner.
  • Demonstrates courtesy and politeness to patients, visitors, callers and other employees.
  • Maintains open channels of communication with center administration and other company departments; Answers all inquiries in a professional and courteous manner.
  • Actively participates in both classroom and online training and other educational opportunities as required.
  • Actively participates in department and organizational meetings as requested.
  • Complies with the organization's policies and procedures and maintains confidentiality in accordance with state and federal laws.
  • Participates in special projects and performs other duties as assigned.

Required qualifications

  • Bilingual in Spanish and English.
  • Ability to work a schedule of Monday – Friday, 8:00 a.m. to 5:00 p.m., with flexibility to work occasional overtime per business needs and occasionally work Saturdays and Sundays for on-site/off-site training and projects.
  • Minimum one (1) year of experience working in a call center in insurance managed care, preferably a Medicare HMO.
  • Basic understanding and ability to apply Centers for Medicare and Medicaid (CMS) regulatory requirements and standard operating procedures.
  • Computer Skills:
  • Proficient in Microsoft Word and Microsoft Excel
  • Minimum of 1+ years of experience working with customer relation management software and/or healthcare records management software

Preferred qualifications

  • Knowledge and experience working with Medicare and Medicare products, preferably through a Medicare Advantage Organization.
  • Knowledge of basic medical terminology.
  • Experience working with provider offices.
  • Experience in assisting providers with claims and authorization inquiries
  • Medical billing and/or coding experience and/or certification

EDUCATION

High School Diploma / GED

Medical billing and/or medical coding certification a plus

LANGUAGE SKILLS

Bilingual English/Spanish fluency.

CERTIFICATES, LICENSES, REGISTRATIONS

N/A

PHYSICAL DEMANDS/WORK ENVIRONMENT

Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays. Position requires the ability to work extended hours when necessary.

The physical demands and work environment characteristics described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors.