Member/Provider Services Representative

Position Summary

The Member/Provider Services Representative is responsible for receiving and making outbound calls to providers and members to ensure customer retention and satisfaction as well as receiving and processing provider applications.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following:

Portraying a positive company image and engaging in professional and friendly communications with customers
Communicate with members and providers by phone and email to verify provider participation
Assist members with provider and claim status and communicate results to members
Receive member and provider requests for network participation and coordinate with network development for completion
Coordinate administration of provider data updates with team members
Maintain complete and accurate updates of provider contracts
Research and resolve provider demographic or claim inquiries
Knowledge of ICD-9, HCPCs, and CPT procedural codes for provider reimbursement schedule maintenance.
Assist department with assigned tasks and projects in a timely manner
Must meet established productivity, schedule adherence, and quality standards
Ensure compliance with HIPAA regulations and requirements
Performing other duties as assigned

Minimum Qualifications (Knowledge, Skills, and Abilities)

The required KSAs include, but are not limited to the following:

Associate degree (A.A. or A.S.) or equivalent from a two-year college, business school, or technical school. Bachelor’s degree (B.A. or B.S) from a four-year college or university preferred.
3 – 5 years’ applicable experience, one of which must be directly related
Or equivalent combination of education and experience.
Excellent oral/written communication skills
Excellent customer relationship skills
Excellent organization skills
Ability to multi-task
Ability to work in a team environment and take direction from management and supervisors
Ability to read and interpret documents such as procedure manuals, work instructions, software manuals; ability to write routine reports and correspondence
One year of experience in a call center environment, including 6 months’ experience in healthcare, medical insurance, or related field.
Knowledge of medical terminology and/or coding practices may be substituted for experience.
Customer service, problem solving, communication (verbal and written), organizational, interpersonal, and follow up skills
Ability to demonstrate reliability and dependability
Ability to handle difficult customers/providers in a professional manner
Ability to communicate verbally while handling multiple applications
Ability to customize communication style to educate customers/providers
Ability to work independently as well as part of a team
Ability to prioritize and manage time
Ability to use software, hardware, and peripherals related to job responsibilities