Representante De Alcance Al Proveedor

Representante de Alcance al Proveedor

Regular

Non-Exempt

GENERAL DESCRIPTION:

Provides administrative support by coordinating service support and maintaining compliance with established protocols. Receives, responds to, and effectively forwards calls and/or requests received in the unit and follows up for prompt issue resolution. Receives and forwards the referrals following the established guidelines. Documents all efforts and maintains the information accurate and exact. Supports the unit with additional administrative tasks as required.

ESSENTIAL FUNCTIONS:

•Contacts providers to offer administrative support for specific projects and unit initiatives, ensuring completion by each project's established due date. This includes re-credentialing, Model of Care (MOC), validation of demographic data, returned checks, invoices, and more.

•Handles and efficiently processes referrals sent to the Unit's mailboxes, including the PCP platform support, telecare support, and reward program support. Provides technical assistance to providers to help them access various technology platforms available in Provinet. In collaboration with the Information Technology Department (IT), coordinates cases that require adjustments to access configurations or updates to reports available to providers across different tools.

•Responsible for assigning to the Service Specialists the referrals received in service emails, Physician Service, Provider Denials and VIP Provider Service. Also, supports Internal Service Specialists who are working remotely handling their Claims adjustment petitions to the Mailing unit for processing.

•Provides service support to the providers through the Apps available for them and refers issues with the App to the technical support team and opens a case number in the documentation tool; once the issue has been solved, notifies the provider, and closes the case.

•Through the Supplemental B mailbox, receives from the Clinical Department cases of members who are required to validate clinical conditions with the PCP (Primary Care Physician) to determine if they qualify for supplemental benefits. Assigns regularly the case to the External Provider Service Specialist to guarantee they can work on it with the provider. Provides follow-up on pending cases that exceed five business days after being assigned to the specialist. Must ensure that the log for this project is kept up to date with the actions taken for each case.

•Supports the case management of members with C-SNP coverage (Chronic Special Need Plan) referred by the Clinical Department to the External Provider Service Specialist for corresponding validations. Performs and completes the documentation of the forms received with the description of the patient's condition in the CRM/RST (Referral System Tool) documentation tool. Sends the final information to the Clinical area for coverage determination.

•Meets quality standards and the average number of calls received or made from/to members or providers on assigned projects.

•Documents the details of the actions taken on calls received and made under each assigned project. Complies with the documentation parameters established in the documentation tool.

•Assists in event coordination, guest, and participant confirmations, as requested.

•Assists in special projects/organizational audits according to operational needs.

•Assists the External Service Specialists with issues related to the Provider's platforms.

• 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: At least sixty (60) approved university credits equivalent to two (2) years of college or an associate degree. At least two (2) years of experience working in Customer Service areas, preferably in a Call Center in the Health Insurance Industry.

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

Certifications / Licenses: Other: Knowledge of medical billing is preferred.

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"