Especialista De Servicio Externo De La Red

Especialista de Servicio Externo de la Red

Regular

Exempt

GENERAL DESCRIPTION:

Responsible for developing, promoting, and maintaining a healthy business relationship with providers taking part in our network, guaranteeing satisfaction, retention, and new referrals of prospects. Main liaison between MCS and the provider to address, coordinate, and solve service situations, situations related to complaints, claims, and operational situations that affect them.

ESSENTIAL FUNCTIONS:

•Main contact for PCPs, specialists, subspecialists, dentists, health allies, and laboratories to address, coordinate, and solve service situations, complying with service quality standards and achieving their resolution within the established period.

•Conducts visits to medical offices to guide the provider according to the operational need at the time.

•Ensure to maintain the frequency of provider visits; PCP in IPA every month, Specialist Provider hired in the VIP Network on a semi-annual basis, and Laboratories and Specialist/Sub-Specialist providers, as required.

•Responsible for guiding and discussing with the PCP the review of the Compensation Plan, identifying areas of opportunity for the provider, and assisting to work on them to improve performance.

•Works with sales on strategies and initiatives related to membership growth and retention.

•Identifies and coordinates branding in medical offices.

•Analyzes the root causes of situations, denials, and/or complaints submitted by the provider to identify the origin of the problem. Refers them to other units and guarantees they are solved following established company policies, procedures, and payment regulations.

•Manages, coordinates, and/or solves situations that require intervention related to providers, such as investigation of complaints and/or situations of improper billing and overcharging of deductibles that result in a breach of contract with regulatory agencies such as AES, OPP, CMS, among others.

•Prepares, documents, and keeps a record of situations reported by Providers in the established tool and makes sure that they are solved.

•Review the claims adjudication process concerning the payment explanation and determine if they are adjudicated correctly.

•Establishes work plans with providers to reconcile their accounts and outstanding balances for closing payment cycles.

•Prepares, manages, and follows up on exception cases presented to the Payment Policy Committee.

•Takes part in the research and implementation of strategies for new projects or modifications in payment processes to providers with specialties.

•Guides the provider on how to bill the appropriate codes according to their specialty, appropriate practices, provider contract, new billing method, and situations under ICD-10 implementation. Coordinate service quality monitoring programs, strategies, initiatives, and educational activities aimed at strengthening relationships with providers and keeping them informed of any changes.

•Uses the change control process established to document new product/service codes, which involves approval from several internal departments (before implementation).

• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.

• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelor's degree, preferably in Business Administration, Health Services Administration, or other health-related fields. At least three (3) years of experience performing functions related to provider service, including, but not limited to, claims processing analysis/investigation, analysis and drafting of reports, and establishment of work plans, preferably in the Healthcare Industry.

"Proven experience may be replaced by previously established requirements."

Certifications / Licenses: Valid driver's license in the Commonwealth of PR is required.

Other: Knowledge of Medical Billing, preferably. Extensive knowledge of provider database systems (i.e., MHS, among others). Availability to work extended hours, weekends, and holidays, according to the business needs and the requirements of the regulatory agencies applicable to the industry.

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"