Provider Service Representative
The Provider Service Representative position requires managing a geographic territory of assigned providers, to include scheduling and making frequent visits to provider offices, assisting with provider issues & concerns, all while having strong initiative and excellent customer service focus. The documenting of visits is a requirement for this position as well, so that there is an accurate reflection of provider issues & concerns. This position will be involved with or generate provider correspondence and other documents as required as well as a base knowledge of the Steward claims & tracking systems, all elements of Steward Health Choice plans processes and policies in addition to AHCCCS, CMS, and HealthCare Exchange plans to enable education of the providers. Sound and objective decision making must be exercised in all interactions with providers and internal departments with excellent verbal and written communication skills.
Provide face-to-face, written and telephone communication to providers:
- Meet with providers to review operational procedures as they relate to Steward, to include, but not limited to, issues surrounding or involving prior authorization, claims/revenue cycle concerns, provider roster/location updates and contracting.
- Provide in-service/education to providers, in the areas referred to above.
- Use the site visit checklist to ensure that all discussion topics are covered.
- Review provider performance in areas such as claims turn-around times, denials & reject reports. (For PCPs, this would include the provider report cards and gaps-in-care report.)
- On an annual basis, ensure all providers review and attest for the Steward MOC training.
- Obtain provider rosters during visits, at least bi-annually.
- Plan visits at least two weeks in advance, and collaborate with management as needed.
- Interact with Claims regarding payment schedules and rates of reimbursement
- Inform providers of policy changes and/or new policies.
- Return telephone calls promptly within 1 business day.
- Respond to written correspondence within 3 business days.
- Provide / facilitate impromptu meetings as required.
- Train new providers within 30 days of contract execution.
- Ensure all offices receive appropriate and necessary provider information including but not limited to: policies, documents, manuals, blast faxes, provider scorecards etc.
- Review and ensure providers follow established policies and procedures and document as such.
- Respond to requests for research and resolution to complaints in coordination with internal departments, as needed or required.
- Communications and items disseminated are complete and accurate.
- Ensure Medical Services are consulted, as required, regarding policies.
- Interacts with Claims regarding payment schedules and rate of reimbursement.
- Claims Manager/Director is consulted on claims procedures (i.e. encounters, reason for denials; etc.).
- Meets department goals and standards.
Develop & provide written materials to providers in order to assist them in following Steward Health Choice procedures:
- Assist with development and distribution of Provider Manual & ensure providers are familiar with it and know how & where to find it
- Assist with the provider newsletter, and participate in Provider Forums
- The Steward Health Choice Provider Manual is developed and distributed
- The provider newsletter and other Steward Health Choice communications are created and distributed.
- Assists in the development of Steward Health Choice policies and procedures as required.
- Providers are notified of new policies and procedures as written.
Maintain and ensure provider demographic information is complete and up to date:
- Review provider rosters to ensure demographics & fee schedules are up-to-date & correct.
- Work with the Resolution Center to ensure our provider database is updated & accurate.
- Ensure that current provider demographic changes & additions are submitted & completed within SLAs.
- Proficient in usage of Microsoft Windows applications
- Knowledge of Medicaid and Medicare programs preferred
- Knowledge of health plan programs desirable
- Excellent ability to plan and organize
- Strong customer service skills and techniques
- Strong presentation and oral and written communication skills
- Ability to negotiate and implement contracts
College Degree preferred
At least two (2) years with excellent customer service experience or claims experience with a managed healthcare plan