Provider Service Helpline Representative

Why Choose Jefferson Health Plans?
We are an award-winning, not-for-profit health maintenance organization. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.
We offer Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We’re also committed to boosting the health of our community through outreach, education, and events. Founded over 35 years ago, Jefferson Health Plans continually develops new ways to encourage better health outcomes and has received national recognition for our innovations in managed care.
While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.
Perks of Jefferson Health Plans and why you will love it here:

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off
• Impact on the communities we service.

We are seeking a talented and enthusiastic Provider Service Help Line Representative to join our team!
Respond to providers’ incoming calls and take appropriate action to resolve providers’ issues across lines of business. Educate callers about the plan and retain providers using effective customer service techniques to provide a high level of service. Dual role supporting incoming calls from both member’s and providers.
As the Provider Service Help Line Representative your daily duties may include:

• 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 Jefferson Health Plans network participation status, status of their credentialing application and fee schedule rate inquiries.
• Educate providers on Jefferson Health 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.

Qualifications

• 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, We Value:

• 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

Profit sharing, Wellness program, Health insurance, 401(k), Paid time off, Flextime, 401(k) matching