Provider Services Advocate (Call Center Support)

POSITION SUMMARY

This position is responsible for responding to provider requests related to provider recruiting and contract interpretation supporting client provider networks.

Educates and promotes various fee for service, Federal Services national programs; building relationships with the local client member companies to achieve common goals; and researching and responding directly &/or indirectly to inquiries from network dentists regarding escalated claims, fees, participation, NPF matters and other issues.
Also responsible to research executive inquiries and take appropriate actions to resolve the provider's issue.
Provides clarification to providers regarding communications issued by the plan in response to regulatory requirements and/or policy changes.
Makes decisions to resolve provider issues in a fast, fair and cost effective manner to ensure provider satisfaction.

ESSENTIAL DUTIES & RESPONSIBILITIES

Responds to provider calls and correspondence related to instructions on network participation, contract interpretation, contracted fees, resolving complex claims and service issues, provider communications and provider terminations at point of contact.
Educates and promotes the various client provider networks; drafts content for various collateral materials for distribution to network dentists; advises local client member company PR staff on program changes, and quickly identifies trends in service issues and recommends course of action.
Builds and maintains strong relationships with the local client member companies to achieve common goals; works to meet the local business needs as well as the Federal Services needs for recruitment and contracting of the PPO network, as needed to support the Network Development business unit.
Assists with provider portal sign-on issues and resets passwords when necessary.
Researches and responds directly and/or indirectly to inquiries from network dentists or local member companies regarding contractual issues, escalated claims, fees, participation, and other provider network related issues.
Resolves 1099, EFT and ERA discrepancies with provider offices; verifies external databases.
Instructs and educates providers on Credentialing process and acts as a liaison between the provider and client to ensure timely processing.
Verifies and updates provider files with new demographic information at point of contact.
Performs other miscellaneous duties as assigned.

QUALIFICATIONS

1+ years of experience w/High School
A minimum of 2 years related experience (Managed Care or Medical/Dental Insurance experience); plus, a minimum of 3 years of related experience working in a large dental or medical plan, provider relations, and operations (claims & customer service).
Strong organizational/time management skills and multi-tasking abilities.
Analytical and problem-solving skills and the ability to make decisions with limited information.
Strong written, verbal, interpersonal and phone skills
Detail orientation with mathematical, reading, and comprehension skills.
Knowledge of Current Dental Terminology (CDT) codes and dental nomenclature.
Ability to type 40 words per minute with no more than two errors.
Knowledge of the company's claims processing systems claims flows and adjustment notices.

EDUCATION, EXPERIENCE & TRAINING REQUIRED

A high school diploma or GED but candidates with proven experience will not be excluded from consideration.
A minimum of 2 years related experience (Managed Care or Medical/Dental Insurance experience).
A Bachelor's degree is preferred. Equivalent experience may be considered in lieu of degree.
A minimum of 3 years of related experience working in a large dental or medical plan, provider relations, and operations (claims & customer service).