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Overview

The Provider Relations Representative is responsible for assisting our provider constituents and providing exceptional customer service.

The Provider Relations Representative will answer incoming calls from health care providers including physician offices, ancillary provider offices and facilities and aid with benefit and eligibility questions, billing and payment questions, and EOB explanations.

The Provider Relations Representative will focus on first call resolution and navigate various systems and programs efficiently to provide the caller with the appropriate information to resolve their issues.

The Provider Relations Representative will develop a relationship with the office staff by providing confident and accurate responses to customer inquiries in a collaborative and professional manner.

The Provider Relations Representative will be accountable to meet all performance measures established in the call center include efficiency and quality metrics as well as first call resolution and attendance.

Qualifications

• High School Diploma or GED required.
• Two (2) years of experience in the health care industry or working in a provider office required.
• Strong working knowledge of CPT, ICD-9-CM, ICD-10-CM and HCPCS coding preferred.
• Experience in Compliance regulations, appeals and grievance knowledge preferred.
• Demonstrated ability to effectively communicate with internal and external customers.
• Excellent written / verbal communication skills and excellent customer service skills required.
• Demonstrated conflict resolution skills.
• Demonstrated proficiency in problem solving and proven ability to prioritize accordingly.
• PC and Windows experience with proficient typing skills and ability to utilize multiple system tools simultaneously.
• Strong organizational / time management skills.
• Proven examples of displaying the IH values : Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

Essential Accountabilities

Servicing and Grievance Appeal Team :

• Research and respond to escalated and complex provider and member inquiries, including claim and billing research requests.
• Provide written and verbal response to customer inquiries.
• Identify and analyze educational opportunities internally or externally.
• Identify potential system configuration or billing issues and provide education to the provider to correct errors.
• Responsible for acting as a customer advocate by providing excellent and accurate customer service when responding to customer requests.
• Utilize up-to-date knowledge of managed care criteria to meet department of health standards.
• Responsible for escalating issues as needed to supervisor.
• Log all contacts into appropriate systems and maintain accurate documentation to meet external audit guidelines.
• Goals : To meet or exceed all department standards in the following categories : Quality goals-measure Representative’s ability to consistently respond to customer with excellent customer service.

Productivity goals-measure Representative’s ability to be productive and use time effectively and efficiently. Includes the volume of correspondence worked daily as well as measuring tardiness and attendance.

Accuracy goals-measure Representative’s ability to respond to inquiries correctly and accurately.

Technical Proficiency :

Maintain technical knowledge regarding Independent Health’s contracts and benefits and working knowledge of policies and procedures and maintaining updates daily.

Attend required training sessions as needed.

Provide accurate and up-to-date information to all customers by documenting all pertinent information into appropriate systems to meet regulatory agency standards (NCQA, State ,CMS etc.

addressing first level complaints and assisting appeals as needed; receive and effectively resolve written inquiries from customers regarding claims, benefits, eligibility, reimbursement and participating providers.

Knowledge of all systems (Siebel, Health Rules, RX Claims, P&W, WNYHealtheNet, MACESS, Focus, E-mail and other systems as needed and the ability to coordinate the use of these tools at the same time.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range : $20 hourly

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off.

The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.

for additional EEO / AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.

Last updated : 2024-05-22