Regular
Non-Exempt
GENERAL DESCRIPTION:
The Provider Service Representative is responsible for answering and making telephone calls to participating and non-participating providers offering services in the service area and outside the plan service area, as well as to policyholders. Guarantees that situations or service needs are solved at the time of the call and, if necessary, refer to their supervisor any situation that cannot be solved according to established operational processes and service guidelines.
ESSENTIAL FUNCTIONS:
Handles all inbounds calls accordingly to the established call protocol to offer quality service and guarantee a first call resolution.
Evaluate, solve, and document the situations presented in the calls by policyholders, members, and providers,
Channeling policyholders, member or providers concern's according to policy and procedures.
Utilizes the telephone system, aligning with their work schedule to maximize call durations, ensuring the Call Center's performance metrics.
Guarantee the established quality and service standards are met in the handling of all received calls.
To achieve compliance with established key performance indicators (KPIs), it is essential that productivity, assigned itinerary, quality of service, documentation of each service, handling of calls, addressing of customer and provider inquiries, and interactions with customers and providers all meet the predetermined percentages and adhere to approved protocols while maintaining a respectful and cordial demeanor.
Responsible for attending and solving service situations between Primary Care Physicians, Specialists, Subspecialists, Dentists, Allied Health Care, Laboratories, and Hospitals participating and not participating in the MCS Classicare and MCS Life Networks.
Educate the provider and their staff on how to access the platform tool, its capabilities, and its functionalities. In addition, supports them in the process of creating and unlocking accounts.
Documents and guarantees that discrepancies in benefits, provider configurations, claim edits, eligibility errors, and Coordination of Benefits (COB) members/policyholders, among others, are corrected.
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: Bachelor's Degree from an accredited institution. At least one (1) year of experience performing duties in a similar position in Customer Service areas, preferably in a Call Center in the Health Insurance Industry.
OR
Education and Experience: Sixty (60) college credits, equivalent to two (2) years of study 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.
OR
Education and Experience: High School Diploma. At least three (3) 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: N/A
Other: Knowledge of medical billing, preferably. Availability to work rotating shifts, Saturdays, Sundays, and holidays, per the operation's requirements.
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"
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