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Provider Services Representative I

Company: Gold Coast Health Plan
Location: Camarillo
Posted on: May 16, 2022

Job Description:

Job DescriptionPOSITION SUMMARYThe Provider Network Operations Representative I, is a member of a cohesive unit that responds to and provides education to providers regarding Gold Coast Health Plan and its health care programs. The Provider Network Operations Representative I will directly represent Gold Coast Health Plan and will focus on maintaining a positive presence in the community. This position includes performing all activities related to provider data base management and internal provider relations functions for the Provider Relations Department. Ensure accuracy and timeliness of data entry of provider network data into the Provider Relations department software. Assist with all provider data management including contracted and non-contracted provider data and other software programs by GCHPESSENTIAL FUNCTIONSReasonable Accommodations StatementTo accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.Essential Functions Statement(s)• Assist with the maintenance of all provider data• Assist Management with the network development team activities to produce timely and positive results• Provide timely handling and completion of assigned projects.• Provide regular and timely reports for all assigned projects. • Improve the efficiency of the Network Operation process and procedures to enhance quality and efficiency• Be able to respond to claims submission questions and have a good understanding of provider claims submissions• Provide timely and accurate submission al of all company requested projects, assignments and reports• Act as a liaison between GCHP provider community to effectively resolve provider issues and concerns• Communicate with telephonically with providers and their staffs to obtain and provide follow up information• Provider face to face provider education• Be Familiar with regulatory requirements around provider data reporting and apply to project workload• Be familiar with Gold Coast Health Plan's contract requirements for PCPs and Specialists.• Work with providers to adhere to contract and regulatory requirements• Data entry, audit, daily maintenance of the PR department master data• Research, review and make updates to user requests within provider data management system• Review provider setup and ensure all records are accurate Update provider and practitioners, facilities (Hospitals and Clinics) status to par by adding claims payment information• Maintain additional provider data reports as needed for Ad Hoc reporting• Participate on internal workgroups related to Provider data management and/or new program implementation• Participate in special projects or reporting as directed by Manager/Director• Perform Provider telephone inquiries around provider data• Develop and maintain data system procedures• Assist with GEO Access data management and reporting• Back up to Compliance/Provider Database Coordinator• Keep Manager and Director informed and updated on all issues and activities• Provider Relations department liaison with other internal departments• Participate in Ad Hoc workgroups as directed by Manager• Projects assigned by the management that involve the Provider Relations/Network Operations Department.• Other duties as assigned by management.POSITION QUALIFICATIONS Competency Statement(s)• Management Skills - Ability to organize and direct oneself and effectively supervise others.• Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.• Customer Oriented - Ability to take care of the customers' needs while following company procedures.• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.• Interpersonal - Ability to get along well with a variety of personalities and individuals.• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.SKILLS & ABILITIESEducation: High School diploma, Associate Degree or certification in Healthcare processes a plus. Minimum 3 (three) years healthcare experience. Must have previous experience with provider data, knowledge of medical terminology and medical provider/practitioner terminology. Project management a plus. Experience: Minimum 3 plus years of experience in the health care field interacting directly with providers.Computer Skills: Advanced computer skills included in the MS Office products. Certifications & Licenses: A valid California Driver's License and insuranceOther Requirements:

  • Act as a liaison between the provider and Gold Coast Health Plan.
  • Excellent written and oral communication skills. Requires ability to prioritize and have excellent organizational skills, maintain accurate records and meet deadlines.
  • Become familiar with internal business systems.
  • Participate in audits and readiness assessments to assess provider data compliance.

Keywords: Gold Coast Health Plan, Camarillo , Provider Services Representative I, Sales , Camarillo, California

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