Representante De Servicio Al Proveedor
GENERAL DESCRIPTION
Answers and makes telephone calls to participating and non-participating providers offering services in the service area and outside the plan service area, as well as policyholders. Guarantees that situations or service needs are solved at the time of the call and, if necessary, refers to their supervisor any situation that cannot be solved according to established operational processes and service guidelines.
ESSENTIAL FUNCTIONS
- 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.
- Makes phone calls from all lines of business according to established call protocol and solves service situations
- Identifies the provider and analyzes the root causes of the situation and/or repetitive complaints submitted by the provider to identify the source of the problem
- Educates the provider and their staff on how to access the Provinet tool, its capabilities, and functionalities. In addition, supports them in the process of creating and unlocking accounts.
- Analyzes electronic claims with error conditions in the Provider Clearinghouse interface to identify and report any corrective actions.
- Receives requests via email, calls, and/or internal referrals for MCS Provinet user and/or password requests.
- Documents 98% of the calls and situations presented by the provider in the established tool according to the established documentation rules. Guarantees that situations are solved following established company policies, procedures, and payment rules.
- Knows and orients the provider on electronic claims status, denial situations and payment explanations, eligibility, benefit availability according to the type of service requested and claims history, co-payments and co-insurance, and applicable pre-authorization requirements, among other transactions.
- Uses all available tools to respond effectively to the service situation presented by the provider.
- Guides providers and Delegated Entities on regulatory processes, HEDIS measures, and/or corporate strategies.
- Documents and guarantees that discrepancies in benefits, provider configurations, claim edits, eligibility errors, and COB members/policyholders, among others, are corrected.
- Complies with the established quality standards:
o Performance Results: Service Level: 75%, ASA: Answer 75% of calls within the first 30 seconds, not to exceed 3% of abandonment rate.
o Quality Results: Customer Satisfaction with the service provided by the representative. Handling the call politely and respectfully. Solution of the service at the first contact.
o Other metrics: Adherence to Itinerary: 97%, Documentation during the Call: 98%, Attends an average of 60 to 70 calls per day compared to team results.
- Complies with and uses the ACD ASPECT UIP connection system, connecting according to their work schedule, maximizing call time to avoid affecting the performance metrics of the call center.
- Complies consistently with the Company’s standards, policies, and procedures, in conjunction with local and federal laws applicable to our industry, business, and employment practices.
MINIMUM QUALIFICATIONS
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.
OR
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
Bachelor’s degree from an accredited institution. At least one (1) year 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 or medical office work, preferably. Availability to work rotating shifts, Saturdays, Sundays, and holidays.
Languages:
Spanish - Basic (writing, conversational, comprehension, and reading)
English - Basic (writing, conversational, comprehension, and reading)
