Provider Services Representative

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

1. Professionally handles a high volume of inbound complex calls originating from the Leon Health Provider Services line.
2. Assists with the processing of inbound correspondence from providers received via physical mail, fax, or e-mail.
3. 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.
4. 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.
5. Identifies provider complaints (disputes/appeals) and ensures the provider is either educated or their complaint is routed to the appropriate department for resolution.
6. Identifies member complaints (grievances/coverage requests/appeals) and ensures these requests are properly classified, addressed, and routed for further review and resolution if needed.
7. Contributes to meeting or exceeding Leon Health Provider Services call center metrics and goals.
8. Follows up with callers to provide response or resolution steps as needed.
9. Clearly documents incoming and outgoing call reasons and dispositions in the call center system.
10. 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.

QUALIFICATIONS

1. Basic understanding and ability to apply Centers for Medicare and Medicaid (CMS) regulatory requirements and standard operating procedures.
2. Computer Skills: Proficient in Microsoft Word and Microsoft Excel

WORK EXPERIENCE

1. Minimum one (1) year of experience working in a call center in insurance managed care, preferably a Medicare HMO.