What are the responsibilities and job description for the Provider Services - Provider Services Representative 115-1023 position at CommunityCare?
JOB SUMMARY:
Primarily responsible for contracting, orientation and ongoing education of physicians, physician office staffs, hospitals and other providers regarding the policies and procedures of CommunityCare Managed HealthCare Plans. Serves as the liaison between the provider community and the health plan.
KEY RESPONSIBILITIES:
Conducts educational and credentialing PCP and appropriate SCP office site visits according to established standards. Provides ongoing education, develops agendas, organizes informational material, facilitates workshops and participates in meetings for assigned networks. Prepares regular correspondence and special mailings to assigned providers.
Researches and responds to issues and inquiries concerning benefits, claims, reimbursement and member issues and recommends appropriate actions to the requesting party. Assist internal departments by contacting provider offices regarding customer service/operational issues/complaints & grievance resolutions and documents appropriately.
Coordinate internal process and procedure among departments to ensure network contract / operational procedures are appropriately reflected in our systems/processes. Participate in departmental processes established to ensure accurate and timely contracting, credentialing, loading and education of providers.
Assist contracting in all phases of the Contracting process established by CommunityCare Managed Healthcare Plans of Oklahoma. Process may include communication with provider during negotiation through completion of executed document implementation of contract, and on-going contract deliverables. Participate in the development of networks and key geographical areas as needed.
Participates in special projects and assignments as directed, including the development of new/improved operating procedures.
Job may contain dimensions that could affect performance of responsibility, which may involve dealing with members who are sensitive and/or emotional.
Perform other duties as assigned.
QUALIFICATIONS:
Possess strong oral and written communication skills.
Ability to monitor and assess rapidly changing information.
Ability to think quickly and respond tactfully to sometimes difficult issues in dealing with providers.
Successful completion of Health Care Sanctions background check.
Proficient in Microsoft applications
Must have a current driver’s license and insurance verification and reliable transportation.
EDUCATION/EXPERIENCE:
Bachelor's degree required OR each year of work experience in a healthcare industry can be substituted for each year of college not completed.
Two to three years of industry related experience in managed care, insurance, physician environment or related area.
Customer Service and sales related experience preferred.
