Senior Provider Experience Representative

Senior Provider Experience RepresentativeJob CodeUSU E33FLSA StatusNon-exemptEEONeuGen is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to: race, creed, color, gender, national origin or ancestry, age, religion, disability, sexual orientation, gender identity, marital status, pregnancy, genetic information, honesty test results, political or Union affiliation, non-job related arrest or conviction records, membership or record in the National Guard, state defense force, or any reserve component of the military forces of the United States or Wisconsin, for the use or non-use of lawful products off NeuGen's premises during non-working hours, or any other characteristic protected by local, state, or federal law.COMPANY OVERVIEWNeuGen, LLC is a shared Services organization, founded in November 2018, based out of Madison, Wisconsin. In 1970, the not-for-profit WEA Trust was founded by the Wisconsin Education Association Council (WEAC). Well known for high-touch, personalized customer service, WEA Trust serves Wisconsin public employees, their staff, and families throughout the state. In 2018, WEA Trust acquired another Wisconsin-based health plan, Health Tradition, in order to serve both public and private employees in the state. Today, NeuGen supports both health insurance companies in addition to providing medical management and administrative services to other healthcare companies.POSITION SUMMARYPosition SummaryThe Senior Provider Experience Representative is responsible for providing excellent proactive service by partnering with providers to improve internal and external operational efficiencies in servicing them. The incumbent is also responsible for monitoring provider contract changes to ensure timely updates and anticipate operational impact and organizational training needs. In addition, the incumbent contacts provider systems to provide additional education and/or training to increase self-service adoption. The incumbent also responds to requests or questions from providers anticipating and proactively informing and educating them on the benefit plan, preauthorization requirements, network status requirements, provider and vendor contracts, reimbursement terms, and payment issues.REQUIRED RESPONSIBILITIESRequired Responsibilities% of Time* Proactive Provider Outreach/Education:* Proactively contact providers to cultivate and maintain productive relationships with a focus on eliminating or reducing provider inquiries and/or issues and promote self-service.* Work with provider systems to understand and remove challenges to adoption and use of self-service tools or automated procedures.* Research and resolve provider operational provider's inefficiencies identified by internal stakeholder.* Partner with high volume providers to improve daily servicing needs i.e., set up weekly calls to service.* Serve as primary contact for:* Internal and external stakeholders to resolve escalations/provider disputes regarding claim payments, discount amounts, denials, timely filing and network status; responding verbally or in writing to explain findings and decision rationale to both.* Out-of-state provider networks (i.e., Equian) and internal staff by receiving and responding to inquiries verbally or in writing regarding payment disputes including reimbursement applied and provider participation inquiries.* Provide support, guidance, and/or clarification to Provider Services Representative(s).* Monitor provider contract changes to ensure timely updates and anticipate operational impact and training needs.55* Inbound Provider Inquiries:* Receive and respond to provider telephone inquiries providing information about member benefits, eligibility, and requirements of the benefit plan.* Inform members about and facilitate the referral and preauthorization process.* Contact, inform, and educate members regarding out of network inquiries, non-covered codes or anything else that could negatively affect the member experience and/or out of pocket costs.* Ensure first call resolution through effective call handling and problem solving.* Own and research calls to completion and resolution, ensuring provider satisfaction.* Determine the applicable policy provisions, guidelines, provider requirements and procedures, and medical review and other procedures that apply to the service.* Consistently announce and transfer providers to the after call survey.* Respond to written provider inquiries about claims and claims decisions.* Assist department efforts to continuously improve service by recommending changes to current practices, identifying training needs, and assisting in the implementation of changes.* Document inquiries in accordance with the department's standards, monitor the types of inquiries received, and report trends and/or concerns to the manager.30* Special Projects:* Identify needs for additional training or references.* Develop and maintain Provider Services department policies and procedures.* Assist in implementation of approved changes to ensure the delivery of high quality, cost effective healthcare to participants.* Perform special projects and assignments including, but not limited to, testing online system changes and enhancements as well as suggesting system improvements.* Assist with and deliver training and orientation of new, existing, and temporary employees on effective use of online systems, portal, references, while demonstrating effective customer service soft skills.15Read OnlyThis job description describes the general nature and scope of responsibilities for this position. Please note other duties and responsibilities may be assigned or removed at any time.REQUIRED QUALIFICATIONSRequired Qualifications* High School Diploma* 4 years of experience working in the health care industry, including four years of experience working in a call or customer care center that required interaction with customers in situations where the customer was no always satisfied.* Knowledge of insurance terminology.* Knowledge of internet for research, calendaring and email, word processing, spreadsheet, presentation, document management and imaging systems/applications (Microsoft Outlook, Word, Excel, Power Point, Health Rules preferred).* Communication skills, including the ability to effectively listen and respond to the presented question or concern, pose substantive questions; and edit and compose correspondence and documentation.* Experience using personal computers, including keyboarding skills, knowledge of Windows-based software; with the ability to efficiently and effectively navigate between different computer programs.REQUIRED SKILLSRequired Skills* Ability to speak persuasively, listen, and pose appropriate questions; convey routine and complex information, decisions, and insurance policy provisions.* Ability to appropriately listen, respond to, and resolve issues for angry, distressed, and/or unreasonable callers.* Ability to compose clear, concise correspondence and narrative reports.* Ability to document complete and appropriate information into the online systems while speaking on the telephone.* Ability to identify problems, collect, organize, and analyze information, and make appropriate decisions or recommendations.* Ability to apply the terms of an insurance policy or contract to a set of circumstances to determine available benefits.* Ability to accurately apply and perform mathematical functions, including addition, subtraction, multiplication, division, and calculating percentages.* Ability to work independently and within a team, be adaptive to critical needs, and share expertise as needed.* Accountable, open, candid, and transparent.* Ability to be composed and adaptive in a dynamic, fast-paced, customer-focused work environment characterized by rapid change, minimal lead times, and multiple competing priorities.* Ability to analyze issues and resolve problems within the scope of the position.* Experience communicating benefit determinations and rationale to subscribers and providers.* Commitment to excellence in customer service.WORK REQUIREMENTSWork Requirements* Ability to work in typical office conditions with frequent use of computer equipment.PREFERRED QUALIFICATIONS AND SKILLSPreferred Qualifications and Skills* Knowledge of medical terminology and reimbursement methodology.* Knowledge of diagnostic and procedure codes.* Knowledge of provider contracting.* Experience communicating benefit determinations and rationale to subscribers and providers.* Knowledge and understanding of Wisconsin's health systems, regional healthcare providers, provider network, provider contracting, integrated healthcare systems, Medicare and Medicaid services, and all associated regulations and related claims processes.* Knowledge of the provider community in Wisconsin and the surrounding states including which provider groups work together and what hospitals are included.OTHEROtherCell Phone StipendAuto StipendCommissionsDISCLAIMERDisclaimerReasonable accommodations may be made to enable individuals with qualifying disabilities to perform the essential functions of the position.#06022021