Why This Role is Important to Us:

　　The Provider Services Department provides a single point of contact for questions, problem solving, and access to care, for providers on behalf of members of the Senior Care Options (SCO) and One Care Programs. The Provider Services Representative (PSR) position is responsible for providing accurate, prompt, and courteous service in response to written and telephonic inquiries from Providers, Vendors, Primary or Interdisciplinary Care Team, and Pharmacies. The PSR will be responsible for responding to a high volume of critical telephonic inquiries from medical providers that directly impact our members’ care. This position is responsible for resolving complex provider issues that may cross departmental lines.

　　Complexity: Responsible for handling calls from providers at all levels of complexity

　　Supervision Exercised: No

　　What You'll Be Doing:

　　Interface with CCA’s provider departments including credentialing, PDM, Provider Relations and Contracting

　　Answer critical incoming phone calls from providers and respond to inquiries, concerns and questions about coverage, benefits, eligibility, and authorization status

　　Navigate through multiple, complex systems and screens while maintaining caller engagement

　　Document all critical information in the appropriate screen and system.

　　Submit providers’ verbal requests for prior authorization and educate providers on PA review process and required documentation

　　Assist providers in resolving claims denials and navigate processes to understand source of denial including Claims Department Registrar, Outgoing Referrals, and Retro Authorization process

　　Communicate rules Continuity of Care to provider and ensure it is applied during coverage determination inquiries

　　Understand and educate providers about different processing timeframes including expedited timeframe

　　Keep up to date on all system and compliance standards and policy changes.

　　What We're Looking For:

　　Education:

　　Bachelor's Degree or equivalent experience

　　Bachelor’s Degree preferred or relevant experience in call center and/or Medicare/Medicaid plan

　　Experience Required:

　　Three plus years

　　Must have experience providing customer-focused service/activities; experience independently problem-solving by referencing information and policies; and experience with data entry

　　Prior experience working in a Call Center required

　　Experience using and entering data into electronic medical records required

　　Must have experience working in a diverse environment: colleagues, members and providers are diverse socioeconomically, ethnically, and culturally

　　Experience Desired:

　　Prior experience working in medical setting preferredKnowledge, Skills & Abilities Required:

　　Proficient knowledge of Microsoft Office Suite

　　Knowledge of Massachusetts’ health care delivery system/services required

　　Must possess exceptional oral and written communication skills, including the ability to manage difficult callers and conflict

　　Must be flexible and comfortable working in an environment that includes continual change for quality improvement

　　Must have the ability to: develop a thorough knowledge of benefits, related payment policies, and medical terminology; work independently as well as within a team environment; prioritize work; and manage and track outstanding work and work due in the future

　　Language(s):

　　Fluency in oral and written English requiredEEO is The Law

　　Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

　　Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.