1. Act as a Provider Advocate.
2. Communicate with contracted and non-contracted Providers by providing information and assistance as appropriate.
3. Assist Providers with interpreting Member eligibility and benefit information for any and all lines of business.
4. Assist with general question about the Programs and Member benefits.
5. Assist with direction on the Provider portal, including how to set up accounts, troubleshooting and navigating the website, how to submit and retrieve necessary information.
6. Handle claim status inquiries, researching and facilitating resolution of payment issues; provider education on remittance advice interpretation and reimbursement, and informing providers of the claims appeals process. 
7. Work closely with the Claims Team in resolving claims discrepancies, inappropriate denials and delays in payments.
8. Provide Vision providers with eligibility; process authorizations and Vision Exception Requests (VERs).
9. Answer questions regarding UM authorizations and denials. Make appropriate changes to authorizations and transfer calls to UM for clinical inquiries Educate providers on Referral process.
10. Assist Behavioral Health (BH) Providers with questions on benefits and guide BH Providers through the Provider portal in submitting online forms.
11. Work closely with Finance Team on possible over-payments and to request assistance with payment verification, including the voiding and reissue of checks, updates to W-9 changes.
12. Meet and Provide Services Call Center Standard Work and performance expectations. This includes, but is not limited to the following:
    a. Successful completion of 6-week Provider Call Center training
    b. Active participation in continuous training
    c. Use telephone system and other equipment appropriately and for professional reasons only
    d. Follow required call scripts and QA requirements
    e. Ability to handle high call volume
    f. Strict adherence to specific work schedule and Attendance and Punctuality Policy
    g. Participate in Provider Call Center meetings, which are held approximately twice a month from 7:00am to 8:00am
    h. Maintain standards for Provider and Member Rights and Responsibilities, such as maintaining Provider and Member confidentiality
    i. Document timely and accurate of all calls received. Over 100% call documentation is required
13. Provide excellent customer service to all callers. Demonstrate a high level of patience and respect with every caller, avoid distractions (reading non-work related materials, using cell phones or other non-work related electronic devices), ensuring each caller is assisted promptly and appropriately and follow Provider Call Center established call handle Quality Assurance Standards and Objectives.
14. Extensive knowledge of all product lines (Medi-Cal, DualChoice, and Healthy Kids) and ability to transfer knowledge to all callers’ inquiries.
15. Assist the Provider Call Center or Provider Services Departments with projects, as needed.
16. Timely follow up with Providers on cases as needed.

Preferred Experience:

• One (1) or more years of healthcare call center experience working in a health care delivery setting preferred.