Job Description

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Hybrid: Applicants must be a California resident as of their first day of employment
PRINCIPAL RESPONSIBILITIES:
Under the general supervision from the Supervisor, Provider Relations Call Center, the Provider Relations Representative I performs a variety of routine and semi-routine tasks requiring a thorough knowledge of organizational policies and procedures. This position will provide administrative and operational support for the Provider Services Department. PR I staff who demonstrate proficiency in meeting, maintaining and exceeding principal performance objectives and metrics may be eligible to be promoted to a Provider Relations II role once they have worked as a PR I for a minimum of 12 months in order to be proficient with program and system knowledge in addition to meeting performance matrix requirements.
Principal responsibilities include:

• Answer incoming provider calls, emails, and other requests for assistance in a timely manner in accordance to departmental performance targets and provide excellent customer service
• Assist providers with basic inquiries about claims, authorizations, benefits, and other issues. This includes working in conjunction with the Medical Services, Member Services, Provider Dispute Resolution Unit and Claims departments.
• Properly document all calls/contacts as required by department standards.
• Participate in regularly scheduled department meetings and trainings.
• Escalate complex issues per departmental standards.
• Follow through with solutions in an accurate and timely manner.
• Effectively maintain the Provider Portal Access and issue resolution processes.
• Effectively handle the departmental inbox and voicemail inboxes
• Maintain files, keep records, prepare schedules, compile reports, and process documents of a routine nature in an accurate and timely fashion.
• Make outgoing calls to providers as directed by other departmental needs and initiatives.
• Adopt and understand changes in benefits, workflow processes, and systems.
• Work in a cooperative manner with other departments.
• Support continuous improvement of provider relations effectiveness through the development, evaluation, and refinement of policies and procedures that meet the operational and regulatory goals and requirements.
• Maintain strict confidentiality of all sensitive information and issues.
• Participate in provider projects if needed.
• Coordinate processing of incoming and outgoing mail.
• Assist with the maintenance of data within various databases.
• Print and distribute information on request.
• Participate in the Provider Services departmental projects and meetings, as needed.
• Assist with other duties and special projects as needed.

ESSENTIAL FUNCTIONS OF THE JOB

• Answer incoming calls, emails, and other requests for assistance in a timely manner in accordance to departmental performance targets and provide excellent customer service while doing so.
• Provide accurate health plan benefits, plan rules, claim reimbursement amounts, and rules, and validate provider data on file. In addition, provide clarification on how the plan operates.
• Conflict resolution: Resolve provider problem/conflicts by meeting with other departmental staff as needed.
• Provider communications: Create and/or mail appropriate provider materials and communications as needed.
• Meetings: Participate in departmental and non-departmental meetings and other scenarios.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or on a computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Constant use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.

Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:

• Two years of college or equivalent work experience.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum one year direct provider service experience required.
• Managed healthcare experience in areas of customer service, claims payment, claims resolution, and/or provider service preferred.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Strong customer service background.
• Excellent critical thinking and problem-solving skills.
• Proficient experience in use in Windows including Microsoft Office suite.
• Ability to work in cooperation with others.
• Ability to communicate effectively, both verbally and in writing.
• Ability to handle multiple projects simultaneously and balance priorities as well as work for a number of individuals.
• Possess strong interpersonal, communication, and listening skills.
• Possess attention to detail and accuracy with solid adaptability skills.
• Ability to work effectively in a multidisciplinary company.

Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department
SALARY RANGE $22.88 - $34.33 Hourly
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.

Skills Required