Resp & Qualifications

PURPOSE:
This role responsible for developing and maintaining positive constituent relationships with providers, operational departments, health institutions and other entities, handling escalated issue management and dispute resolution activities. Serves a primary liaison to provide communication, education, issue resolution and support to network providers.

ESSENTIAL FUNCTIONS:

Partners with Provider Training and Education Department to educate providers ensuring they are engaged in the value of our programs in support of positive member interactions. Provide ongoing and targeted basic training and education to our provider community ensuring they can successfully utilize electronic tools, navigate provider portal, follow processes and procedures.
Involved in supporting one or more health systems, representing multiple practices, enabling the organization to provide Tier One Service.
Provide research, analytic and resolution support for less complex special projects.
Provide research, analytic and resolution support on special cases and projects ensuring that all policies and contractual guidelines are clearly identified as required by the case. Provide verbal or written responses to inquiries to management and other internal and external customers. Acts as a resource and provides needed assistance to providers in resolving escalated service-related issues and timely response to provider inquiries via face to face visit, correspondence, e-mail, phone, etc.
Build and maintain appropriate relationship with providers by ensuring regular communications and timely problem resolution. Leverages provider relationships to drive and influence provider behavior towards favorable outcomes
Proactively identifies provider needs and responds appropriately through problem solving, engagement of other internal or external resources, and providing high level service

QUALIFICATIONS:

Education Level: High School Diploma.

Experience: 4 years experience in the customer service, including experience working experience with providers, training, claims, and presentations.

Preferred Qualifications:

This position supports the DC Medicaid line of business.

Previous experience with DC Medicaid and managed care organization operations strongly preferred.
Call center, customer service, health claims terminology familiarity required.
Issue resolution and problem solving skills are essential to this role.
Bachelor's Degree in business, healthcare administration or related industry.
Previous experience with CareFirst BlueCross BlueShield, an insurance plan, a hospital, or a physician hospital organization (PHO) is a huge plus.

Knowledge, Skills and Abilities (KSAs)

Working knowledge of provider billing and coding mechanisms.
Thorough knowledge of managed care industry legislated and regulated requirements, health care financial matters and third-party payment methodologies.
Understanding of contractual documents and ability to effectively communicate terms to providers.
Working knowledge of Microsoft Excel, Microsoft Access, Microsoft PowerPoint and Microsoft Word.

Travel Requirements:
Estimate Amount: 50% Frequent travel to provider offices, hospitals, medical offices.

Department

Department:DC Medicaid - Provider Service

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.

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