• Provider Relations Representative I

    Location US-CA-Alameda
    Posted Date 4 weeks ago(4/24/2018 2:19 PM)
    Job ID
    # of Openings Remaining
  • Overview

    Under the general supervision from the Director, Provider Relations, 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/Network Management Unit.


    Principal responsibilities include:


    · 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 while doing so.

    · Assist providers with basic inquiries about claims, authorizations, benefits, and other issues. This includes working in conjunction with the Medical Services, Member Services 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.

    · 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, work processes, and systems.

    · Create and/or collaborate on communications pieces and member material items. 

    · 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 or member orientations and other outreach events when requested.

    · Coordinate processing of incoming and outgoing mail.

    · Provide administrative support in the following areas:

    -     Provider Directories

    -     Provider Manual

    -     Quarterly DCP Reports

    -     Quarterly Provider Bulletins

    -     Periodic Fax Blasts

    -     Provider Surveys

    -     Provider Meetings

    · Assist with the maintainence of data within various databases.

    · Print and distribute information on request.

    · Participate in the Provider Services/Network Management Unit and other departmental projects and meetings, as needed.

    · Assist with other duties and special projects as needed.





    · Provider Customer Service: Receive and document telephone calls, emails, and other sources of contacts from members, potential members, and providers and explain health plan benefits, plan rules, reimbursement amounts and rules, and validate provider data on file. Provide clarification on issues regarding patient and physician rights and 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 member materials and communications as needed.

    · Meetings:  Participate in departmental and non-departmental meetings and other scenarios.

    · Computer:  Perform ongoing data entry which assists in the maintenance of the Network Management department database to ensure data integrity.

    · Assist in the maintenance of various databases to ensure integrity of data; word-processing; and preparing occasional spreadsheets for presentations and publications.

    · Filing:  Maintain provider credentialing files as well as inter-departmental files.

    · 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 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.




    · Two years of college or equivalent work experience.





    · Minimum two years direct customer service experience required.

    · Managed care experience in areas of customer service, claims payment, claims resolution, and/or provider service preferred.




    · Strong customer service background.

    · Excellent critical thinking and problem solving skills.

    · Proficient experience in use in Windows including Microsoft Office suite.

    · Ability to work in cooperation with others.

    · Ability to communicate effectively, both verbally and in writing.

    · Ability to handle multiple projects simultaneously and balance priorities as well as work for a number of individuals.

    · Possess strong interpersonal, communication, and listening skills.

    · Possess attention to detail and accuracy with solid adaptability skills.

    Ability to work effectively in a multidisciplinary company


    Pay Range:

    $18.57 - $27.86



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