Provider services representative job description

Molina Health Plan Provider Network Management and Operations jobs are responsible for network development, network adequacy and provider training and education, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Provider Services staff are the primary point of contact between Molina Healthcare and contracted provider network. They are responsible for the provider training, network management and ensuring knowledge of and compliance with Molina healthcare policies and procedures while achieving the highest level of customer service.
KNOWLEDGE/SKILLS/ABILITIES


This role serves as the primary point of contact between Molina Health plan and the Provider community that serves Molina members. It's an external-facing, field-based position requiring a high degree of job knowledge, communication, and organizational skills to successfully engage high volume, high visibility providers (including senior leaders and physicians) to ensure provider satisfaction, education on key Molina initiatives, and improved coordination and partnership.



Under minimal direction, works directly with the Plan's external providers to educate, advocate, and engage as valuable partners, ensuring knowledge of and compliance with Molina policies and procedures while achieving the highest level of customer service.
Conducts regular provider site visits within assigned region/service area. Determines own daily or weekly schedule, as needed to meet or exceed the Plan's monthly site visit goals. A key responsibility of the Representative during these visits is to proactively engage with the provider and staff to determine, for example, non-compliance with Molina policies/procedures or CMS guidelines/regulations, or to assess the non-clinical quality of customer service provided to Molina members.
Provides on-the-spot training and education as needed, which may include counseling providers diplomatically, while retaining a positive working relationship.
Independently troubleshoots problems as they arise, making an assessment when escalation to a Senior Representative, Supervisor, or another Molina department is needed. Takes initiative in preventing and resolving issues between the provider and the Plan whenever possible. The types of questions, issues or problems that may emerge during visits are unpredictable and may range from simple to very complex or sensitive matters.
Initiates, coordinates, and participates in problem-solving meetings between the provider and Molina stakeholders, including senior leadership and physicians. Such meetings would occur to discuss and resolve issues related to utilization management, pharmacy, quality of care, and correct coding, for example.
Independently delivers training and presentations to assigned providers and their staff, answering questions that come up on behalf of the Health plan. May also deliver training and presentations to larger groups, such as leaders and management of provider offices (including large multispecialty groups or health systems, executive level decision makers, Association meetings, and JOC's).
Performs an integral role in network management, by monitoring and enforcing company policies and procedures, while increasing provider effectiveness by educating and promoting participation in various Molina initiatives. Examples of such initiatives include administrative cost effectiveness, member satisfaction - CAHPS, regulatory-related, Molina Quality programs, and taking advantage of electronic solutions (EDI, EFT, EMR, Provider Portal, Provider Website, etc.).
Trains other Provider Services Representatives as appropriate.
Role requires 80%+ same-day or overnight travel. (Extent of overnight travel will depend on the specific Health Plan and its service area.).



JOB QUALIFICATIONS


Required Education


Bachelor's Degree or equivalent provider contract, network development and management, or project management experience in a managed healthcare setting.


Required Experience



2 - 3 years customer service, provider service, or claims experience in a managed care setting.
Working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicaid and Medicare lines of business, including but not limited to, fee-for service, capitation, and various forms of risk, ASO, etc.



Preferred Education


Bachelor's Degree.


Preferred Experience



5 years' experience in managed healthcare administration and/or Provider Services.
5 years' experience in provider contract negotiations in a managed healthcare setting ideally in negotiating different provider contract types, i.e., physician, group and hospital contracting, etc.




To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.


Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.


#PJHPO

Founded in 1901, ChildCareGroup’s (CCG) mission is to champion a strong early childhood system that teaches children and parents, trains early childhood professionals, and assists families. ChildCareGroup believes that children do better as their parents do better. When families thrive, communities succeed.

ChildCareGroup offers a generous benefits package including Paid Parental Leave, (12) Company Holidays, 401(k) match, Paid Time Off, Medical, Dental, Vision and more!

You are a great fit for the role because you identify with the CCG SPIRIT, our core values:

SERVICE – Lead with a servant’s heart

PROFESSIONALISM – Perform our best every day

INTEGRITY – Do what is right

RESPECT – Treat each other the way we wish to be treated

INCLUSION – Value individual differences

TEAMWORK – Communicate and collaborate to achieve our goals

Position Details

Responsibilities

• Works with providers as they request to join the CCA program or are requested by the eligible parent. Sends required paperwork to provider and tracks documents to ensure all required items are received. Determines provider eligibility.
• Provides technical assistance via telephone, email, or virtual meeting to the provider on forms, program guidelines, attendance reporting, and payment procedures.
• Provides customer service via the provider help line; answers calls promptly, provides assistance with CCA requirements, documents information in the state database and internal workflow system as needed, sends requested information to providers. Assists customers who visit the office in person.
• Processes provider paperwork, accurate rate reimbursement, and documentation for providers in the state database and internal workflow system while maintaining a high level of accuracy on data entry.
• Reviews confidential documents submitted by relative providers to determine proof of relationship and overall eligibility. Handles EIN/Social Security numbers as well as banking information. Ensures that documentation accurately and clearly reflects any activity with the provider. Ensures all confidential information and documentation is kept secure.
• Performs other duties as assigned by Supervisor/Manager

Education and Experience

• High school diploma or equivalent required, Associates degree preferred
• One year employment experience in customer service or general office setting required
• Must have demonstrated success working as a member of a team
• Must display excellent written and verbal communication skills and effectively work with the public
• Good organizational skills and proven ability to work under pressure and meet deadlines required
• Must be able to produce documents with little or no grammar and spelling errors
• Computer literacy required (e.g., MS Office suite, Adobe, etc.).
• Prompt and regular attendance required

Travel and Compliance Requirements

• Must have a valid Texas driver's license
• Driving record must comply with CCG's automobile insurance carrier requirements
• Must have liability insurance coverage and reliable personal transportation
• Ability to travel locally or out of town as required
• Mileage reimbursement is offered when applicable
• Must successfully meet all compliance background check requirements for federal funding throughout employment
• In accordance with the applicable directives from the Federal government and the Office of Head Start regarding COVID-19 vaccine requirements, all CCG employees must be fully vaccinated by January 4, 2022.

ChildCareGroup’s Generous Health and Wellness Benefits

• Paid Parental Leave
• Short Term, Long Term Disability and Basic Life Insurance at no cost
• Medical, Dental and Vision Insurance
• Telemedicine at no cost
• 401(k) with a company match
• Paid Time Off
• (12) Paid Company Holidays
• And more!

Become a part of the team that supports the education and assistance of over 50,000 lives per year in Texas!

ChildCareGroup is an Equal Opportunity/Affirmative Action employer.

#childcare #providerservicesrep

About Accolade

Accolade (Nasdaq: ACCD) provides millions of people and their families with an exceptional healthcare experience that is personal, data driven and value based to help every person live their healthiest life. Accolade solutions combine virtual primary care, mental health support and expert medical opinion services with intelligent technology and best-in-class care navigation. Accolade's Personalized Healthcare approach puts humanity back in healthcare by building relationships that connect people and their families to the right care at the right time to improve outcomes, lower costs and deliver consumer satisfaction. Accolade consistently receives consumer satisfaction ratings over 90%. For more information, visit accolade.com.

Role overview

Provider Health Assistants (PHA) answer inbound calls from provider offices regarding patient-related services such as verification of benefits, verification of eligibility, pre-certification, and other general physician-patient care support needs.

A day in the life…

* Answering calls in a high volume, fast paced call center environment,
* Seeking to understand the context behind the provider's call by probing for information to understand the provider's questions or support needs in order to ensure first call resolution;
* Navigating and engaging multiple systems, and pulling the puzzle pieces together to resolve provider questions, complex issues and requests;
* Offering guidance to providers regarding their patient's eligibility, coverage, pre-certification denials and appeals processes;
* Educating providers on how to reduce errors in pre-certification process due to lack of information, and educating them on how to most effectively support their patients in the appeals process;
* Navigating and providing input to policies, systems, methods, and procedures for the effective management of key business processes;
* Performing other relevant tasks, as needed.
*

What we are looking for…

* High School Diploma/GED
* 1+ years employment experience in the customer service industry, the service industry, administration, or reception
* 1+ years hands on experience with web-based applications
* Excellent customer service skills; strong verbal and written communication
* Ability to respond empathically
* Experience resolving benefits and provider network questions in a fast paced, call center environment
* Ability to answer the unasked questions providing first call resolution
* Ability to navigate multiple systems and multi-task
* Ability to de-escalate tense situations and turn them into productive, resolve-oriented conversations
* Ability to navigate basic math scenarios including percentages, premiums/payments and out of pocket expenses (deductibles/coinsurance/copays)
* Bi-lingual preferred

We strongly encourage you to be vaccinated against COVID-19.

What is important to us...

Creating an enduring company that is hyper-focused on our culture and making a meaningful impact in the lives of our employees, members and customers. The secret to our success is:

We find joy and purpose in serving others

Making a difference in our members' and customers' lives is what we do. Even when it's hard, we do the right thing for the right reasons.

We are strong individually and together, we're powerful

Trusting in our colleagues and embracing their different backgrounds and experiences enable us to solve tough problems in creative ways, having fun along the way.

We roll up our sleeves and get stuff done

Results motivate us. And we aren't afraid of the hard work or tough decisions needed to get us there.

We're boldly and relentlessly reinventing healthcare

We're curious and act big -- not afraid to knock down barriers or take calculated risks to change the world, one person at a time.

Accolade is an Equal Opportunity and Affirmative Action Employer committed to advancing an inclusive environment for all qualified applicants and employees. We provide employment opportunities, without regard, to any legally protected status in accordance with applicable laws in the US. We are committed to help ensure you have a comfortable and positive interview experience.

Accolade, Inc., PlushCare, Inc., and Accolade 2ndMD LLC will never ask you to pay to get a job. Anyone who does this is a scammer. Further, we will never send you a check and ask you to send on part of the money or buy gift cards with it. These are also scams. If you see or lose money to a job scam, report it to the Federal Trade Commission at ReportFraud.ftc.gov. You can also report it to your state attorney general.

To review our policy around data use, visit our Accolade Privacy Policy Page. All your information will be kept confidential according to EEO guidelines.

RSRACC

Accolade