Job Description

Representante de Servicio al Proveedor

Regular


Non-Exempt

GENERAL DESCRIPTION

The Provider Service Representative is responsible for answering and make 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, 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 call by policyholders, members, and providers. Channeling policyholders, member or providers concern's according to policy and procedures. Uses ASPECT VIA telephone platform, connecting according to their work schedule, maximizing call time. By doing so, they can contribute to the Call Center performance metric. Guarantees the established quality and service standards are met in the handling of all received calls. Compliance with the established key performance indicators established in their annual goal planning, such as, but not limited to:

o Productivity - according to the percentage established with the result of the business line.


o Itinerary assigned - according to the percentage established.


o Quality of service - according to the percentage established.


o Documentation of each service provided to the customer - according to the percentage established


o Calls answered or made should comply with established and approved protocols.


o Requests or questions from customers or providers were addressed and referred to correctly, appropriately,


and promptly.


o Interaction with the customer or provider must be appropriate, cordial, and respectful.

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. Educates the provider and their staff on how to access the Provinet 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 Accion Afirmativa para reclutar a Mujeres, Minorias, Veteranos Protegidos y Personas con Impedimento"