Provider Service Representative III

Salary Range: $55,245.00 (Min.) - $69,045.00 (Mid.) - (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Provider Service Representative (PSR) III is the first point of contact for providers and stakeholders, delivering complete and accurate support on eligibility, benefits, claims, authorizations, Primary Care Physician (PCP) changes, and other service needs ensuring seamless support across the provider service journey.

The PSR III focuses on all managed care product lines with an in-depth understanding of benefits and claims processing across all products. Acts as a Subject Matter Expert (SME), serves as a resource and mentor for other staff.

Duties

Responds to inquiries across all channels related to eligibility, benefits, claims, authorizations, and coordination of care. Assists providers with navigating member eligibility, benefits and claims processing. Provides First Call Resolution (FCR) by addressing the needs of our providers effectively on the first call. Supports providers with navigation of self-service tools. Documents all interactions in L.A. Care’s system of record. Ensures compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and protects member privacy. Triages and directs calls to the appropriate internal teams or external entities for resolution, as needed. (70%)

Supports the Contact Center operations in meeting call performance goals by assisting member-related inquiries, as needed. (10%)

Supports ad-hoc targeted member outreach activities as determined by business need. (5%)

Applies subject matter expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, provides mentorship, and contributes specialized knowledge. Ensures that the facts and details are correct so that the program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training and recommends process improvements as needed. (5%)

Performs other duties as assigned. (10%)

Duties Continued

Education Required

High School Diploma/or High School Equivalency Certificate

Education Preferred

Experience

Required:

At least 3 years of Managed Care experience in provider relations or customer service, including 1 year of experience handling provider inquiries related to claims, benefits, authorizations, and payments in a contact center environment.

Data entry experience with ability to type a minimum of 40 wpm.

Skills

Required:

Ability to answer a high volume of calls while demonstrating a high level of empathy and patience.

Knowledge of managed care terminology and claims processing.

Knowledge of HIPAA regulations and confidentiality practices.

Excellent verbal and written communication skills.

Excellent probing, problem-solving and multitasking skills.

Ability to coach, mentor, and support Contact Center representatives.

Ability to work independently with minimal supervision.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Preferred:

Technical training/certificate in a technical or business school (e.g. medical billing, medical terminology, medical coding, healthcare).

Physical Requirements

Light

Additional Information

L.A. Care Health Plan’s Contact Center is open 24 hours a day, 7 days a week, including holidays. Contact Center work shifts are assigned based on business need and may include, but not be limited to, evenings, weekends and holidays.

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offers a wide range of benefits including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)

Nearest Major Market: Los Angeles
Job Segment: Claims, Customer Service Representative, Medical Coding, Data Entry, Insurance, Customer Service, Healthcare, Administrative