Provider Specialist

Fallon Health•Worcester, MA

1d•$25 - $25

About The Position

Respond to physician, hospital, ancillary provider inquiries and requests for services associated with the resolution of provider complaints relating to operational concerns, policy and procedures for Fallon Health products and subsidiaries. Understand Fallon Health policies and facilitate and the research required to resolve provider issues. Work collaboratively with internal departments to resolve provider items and look for process improvements. Validate and Update provider demographic and practice changes applicable to the assigned provider territory. Update provider demographic and non contractual changes in QNXT/eVips accurately and timely.

Requirements

Bachelor’s degree or equivalent combination of training and experience
A verifiable high school diploma or GED is required for all positions at Fallon Health and its affiliates, unless specified otherwise.
2 years’ experience in a customer service role for a healthcare services organization
Proficiency with desktop computer applications, Microsoft Office package, mainframe knowledge (QNXT/eVips)
Knowledge of medical terminology/claims payment, ICD and CPT coding familiarity
Exemplary customer relations expertise
Clear concise written and verbal communication skills
Ability to manage, organize, document and prioritize multiple tasks simultaneously

Responsibilities

Receive daily calls and email correspondence from assigned physicians, hospitals, and ancillary providers requesting information and services.
Act as primary point of contact with assigned providers by promoting a one-stop customer service for escalated provider service issues. Escalations come from internal departments and external provider contacts.
Utilize appropriate internal resources in order to analyze and resolve issues.
Monitor status of QNXT cases thru to resolution status. Maintain detailed documentation within QNXT cases. Conduct proactive follow-up activities with provider and/or Fallon Health staff.
Validate data received by providers and update demographic and practice changes at the request of the assigned provider.
Adhere to departmental, corporate standards and policy and procedure (i.e., Fallon Health Service Level agreements) issue resolution timeframes, PUNKS, QNXT case inventory/assignments, etc.)
Assist and support the Provider Relations Representative on Provider enrollment initiatives.
Escalate critical issues and conflicts to Manager, Provider Data or Sr. Director, Benefit and Provider Configuration as appropriate.
Maintains assignments related to assigned territory, [i.e., internal Joint Operations Committee meetings, provider contract knowledge, PCP reports (changes, additions, deletions)], as appropriate.
Participate in external and internal provider meetings for assigned provider territory on a schedule or dependent upon urgency identified by Manager.
Manage all Provider Adds/Updates in the eVIPS application
Process any Group/Facility needs as identified by the Contracting Team in the eVIPS application