Provider Service Helpline Representative

Job Details

Job Description

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
• Review claims details and submit for reconsideration as appropriate
• 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 or 3 years of Equivalent work experience required.
• Minimum of 2+ years of call center experience, inbound/outbound telephone experience or equivalent face to face customer service experience within 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.
• Working knowledge of HCPCs and ICD-10 coding preferred.
• Medicaid, CHIP, Medicare knowledge is a plus.
• Strong relational database experience, Proficient in Microsoft Outlook and Excel and working knowledge of Microsoft Word

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.