Senior Provider Service Representative

UnitedHealth Group • San Diego, CA

15h • $20 - $36 • Hybrid

About The Position

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.
This is a critical position within the Provider Services Department and a required position within our contract budget. This is a budgeted replacement position that is funded by the ASO contract with the County of San Diego. The position is critical to maintaining the Fee for Service Provider Network that we manage on behalf of the County. This position is responsible for processing the provider applications & contracts, completing the provider credentialing and re-credentialing.
The Senior Provider Services Representative role is focused on managing provider networks that support the client base, including hospital, FFS and TERM networks. Responsibilities may include provider relation activities, analyzing provider performance, credential and recredentialed activities, and creating provider reimbursement arrangements. Demonstrates thoroughness and attention to detail to reviewing tasks and documents. Proactively engages in effective communication with diverse audiences and providers. Maintains tasks accuracy especially under tight work deadlines. Consistent with productivity goals and departmental expectations.
Responsible for the full range of provider relations and service interactions. Works with Manager of Provider Services on processing applications and related documents; completing credentialing process in conjunction with Corporate Credentialing Department staff. Maintains and ensures the integrity of provider databases; responds to provider inquiries and provides exceptional customer service to providers, County partners, peers, staff in other departments and the general public. The Contract Administrator may work with providers on the TERM, and/or Medi-Cal Fee-For-Service (FFS) Network(s) as well as Off Panel, Out of Network providers, Skilled Nursing Facilities, Hospitals, which includes the San Diego County Psychiatric Hospital and/or Edgemoor Hospital, as well as other medical professionals.

Requirements

• High School Diploma/GED
• 1+ years of data entry experience
• 1+ years of experience with provider contracting
• 1+ years of experience in the behavioral health managed care environment
• Intermediate level of proficiency with Microsoft Office applications

Nice To Haves

• Knowledge of EHR, SmartCare
• Excellent verbal, written and interpersonal skills required, including experience drafting correspondence and preparing meeting documentation
• Knowledge of reporting and data analysis required
• Familiarity with SmartCare or other Electronic Health Record (EHR) systems, or similar platforms
• Solves moderately complex problems on their own and with the team
• Work is frequently completed without established procedures
• Ability to work independently and collaboratively in a fast-paced, multi-departmental environment
• Capable to act as a resource for others
• Proactively identifies solutions to non-standard requests
• Applies knowledge/skills to a range of moderately complex activities
• High level of professionalism and integrity
• Exceptional organizational and time management skills
• Commitment to fostering diversity and inclusion across provider networks and organizational practices
• Strong focus on achieving measurable results and driving continuous improvement

Responsibilities

• Manage provider interactions and ensuring ease of the provider portal, including future service enhancements
• Supports the development and delivery of external provider education and training programs
• Assist the Manager and Leadership in updating and developing provider data, workflows, systems, and other processes
• Supports credentialing, recredentialing, enrollment and contracting processes, including Letters of Agreement (LOAs) ensuring compliance with NCQA or County standards
• Orders and supports Primary Source Verification for Providers
• Oversees and maintains updated provider credentialing documentation, including but not limited to DEA registration, clinical license, board certifications, and PLI
• Completes administrative processes related to the applications and supporting documents to ensure compliance with credentialing criteria for inclusion in the FFS and TERM provider networks
• Collaborates with cross-functional teams to ensure seamless execution of site-wide processes
• Responds to provider requests (emails, calls, mail correspondence, and faxes) and inquiries and direct them to appropriate internal or external resources
• Designs and implements programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers
• Contributes to the development and management of provider network strategies
• Identifies gaps in provider network composition and services to assist the network contracting and development team in prioritizing contracting needs
• Involved in identifying and remediating operational short-falls and researching and remediating claims
• Follow up with providers to obtain the necessary supporting documents and attestations required for contracting to maintain their network participation
• Ensure provider and group system setup forms are accurately completed and submitted to the appropriate internal departments for processing
• Plans, prioritizes, and organizes and completes tasks to meet established goals and deadlines
• Designs and delivers comprehensive, effective training that aligns with departmental goals and meets the needs of team members
• Develop report templates and generate reports to support provider data analysis
• Actively participates in meetings to support the achievement of departmental and cross-functional goals and objectives
• Perform and accurately enter and update provider data across multiple databases used for directories, payments, mailing, and reporting
• Maintain organized provider files for easy access by staff, leadership, and other departments
• Conducts peer review of providers’ files to ensure accuracy and current supporting documents
• Document provider communication in designated systems and helps maintain database integrity by verifying and updating provider information during interactions
• Provides support to Manager and Leadership in preparation for the annual audit
• Performs additional duties as assigned by Manager to successfully support the Department, Leadership, provider networks, and team

Benefits

• Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
• Medical Plan options along with participation in a Health Spending Account or a Health Saving account
• Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
• 401(k) Savings Plan, Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED