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Helpline Agent\Member Relations Representative

Philadelphia, 901 Market Street, Philadelphia, Pennsylvania, United States of America Req #974
Thursday, February 21, 2019

We are proud to be an EEO/AA employer M/F/D/V. Minority and women are encouraged to apply. We maintain a drug-free & nicotine free workplace and perform pre-employment substance abuse testing.

General Description:

 

Respond to participating providers’ incoming calls, and take appropriate action to resolve providers’ issues.  Educate callers about the plan and retain providers using effective customer service techniques to provide a high level of service. Dual role supporting incoming calls from both member’s and providers

 

Primary Responsibilities:

 

  • Provide accurate and complete information in response to providers’ inquiries, complaints and/or problems. 

  • Collaborate with internal departments to facilitate resolutions to provider issues and concerns

  • Respond to provider related calls in a courteous, professional & efficient manner providing timely follow-up to requests for information and service.

  • Respond to provider inquiries regarding member eligibility, Third Party Liability (TPL) and benefits

  • Document all calls in accordance with departmental requirements

  • Review claims in the core processing system and provide high level claim status to provider inquiries

  • Provide member authorization statuses upon request

  • Confirm which services require prior authorization upon request

  • Educate providers on Provider Portal capabilities (i.e. reset passwords and duplicate EOP request)

  • Reference and review the providers contract and provide basic information to contractual inquires

  • Operate telephone systems effectively and efficiently, following established protocols for security, transfer and information exchange with the Utilization Management, Pharmacy and Claims Services departments

  • Meet individual performance standards, such as satisfactory volume of calls, and telephone and paperwork audits.

  • Advise providers upon request of their Health Partners Plans network participation status, status of their credentialing application and fee schedule rate inquiries

  • Educate providers on Health Partners Plans programs and policies, as appropriate.

  • Maintain resources relevant to the job, such as the provider manual and the department’s training manual to ensure accurate responses to provider inquiries

  • Participate in ongoing projects, training, staff and/or committee meetings

  • Perform other job duties as necessary.

     

Key Job Requirements:

 

Education:       High school diploma.  Two–three years managed care customer service experience preferably in a provider-facing environment

 

Skills/Abilities: Demonstrated organizational, analytical, written and verbal communication skills and interpersonal skills required. Claims experience preferred. Possess the ability to work independently and as part of a team. Contain working knowledge of HCPCs and ICD-10 coding.  Strong relational database experience, Proficient in Microsoft Outlook and Excel and working knowledge of Microsoft Word

 

 

Compliance Statement:  Compliance with all applicable rules, regulations and laws is a condition of employment.  Employees must read and sign, both the Business Code of Conduct and the Personal Standard Code of Conduct, and are expected to perform their duties ethically and honestly.

Medicare Advantage Compliance Statement:  Compliance with all applicable rules, regulations and laws is a condition of employment.  Employees must read and sign, both the Business Code of Conduct and the Personal Standard Code of Conduct, and are expected to perform their duties ethically and honestly.

Access To Protected Health Information:

Other details

  • Pay Type Hourly
  • Required Education High School
  • Philadelphia, 901 Market Street, Philadelphia, Pennsylvania, United States of America