Provider Inquiry Representative I (Hybrid/Troy, MI) - Health Alliance Plan

General Summary:
This position has the following primary objectives with respect to customer relations for all Health Alliance Plan product lines: (1) Provide courteous and prompt resolution to provider inquiries by conducting thorough investigations and fully educating provider/customers; with the goal of resolution upon initial customer contact; (2) Support corporate and departmental goals, provider engagement and education activities and product launches; (3) Research and investigate service failures and report to leadership; identify root cause and recommend resolutions for service recovery and retention.
Principal Duties and Responsibilities:
Respond to inquiries received by telephone, mail and fax; research and answer inquiries, complaints and appeals by following all department standards, policies and procedures; direct inquiries via Pega to supporting departments for appropriate action and resolution.
Educate existing and potential providers on policies, procedures, products, benefit plan and coverage provisions related to all Health Alliance Plan products.
Document all incoming inquiries in Pega to track provider inquiries and communicate trends as they are identified.
Practice and maintain confidentiality to Privacy and HIPAA regulations. Proactively seek training and development to enhance skills and abilities.
Monitor workflow inbox and outstanding cases to ensure that all inquiries receive an appropriate response in a timely manner; Contact providers (by phone/or in writing), as needed, to ensure timely resolution and follow-up to inquiry.
Interact with support departments in a professional manner to ensure provider needs are met. Develop and maintain strong business relationships with inter-departments; Continue to self-educate on changes in policies and procedures that occur in other departments which could have an impact on department operations and the servicing of provider/customers.
Attend training and development sessions or continuing education opportunities offered by Customer Services and maintain enhanced skill levels and performance.
Interact with providers and the staff at the billing offices to obtain information for resolving customer inquiries/complaints.
Ensure and maintain compliance of all department and corporate standards, policies and procedures.
Recommend process improvements based on observations and trends identified while interacting with internal and external customers.
Perform other related duties as assigned.
Education Required:
Associate’s Degree in Business or related field or minimum four (4) years of related experience may be considered in lieu of degree.
Course in Medical Terminology (will be requirement to complete post-employment).
Experience Required:
Minimum of two (2) years of recent Customer Service or Call Center experience within the last three years (Claims Call Center experience preferred).
At least one (1) year of healthcare provider claims processing or billing experience or at least 1 year experience servicing healthcare providers relative to claims and benefits in a managed care setting within the last 5 years.
Skills and Abilities:
Must be dependable
Handle assigned projects from start to successful completion
Handle multiple priorities concurrently in a timely and accurate manner
Demonstrate excellent listening, verbal and written communication skills
Demonstrate excellent problem solving skills
Must have strong interpersonal skills
Demonstrate a high degree of integrity, patience, maturity, empathy, tact and diplomacy
Demonstrate flexibility, good judgment and ability to provide service excellence
Business writing skills
Efficiency in using a PC and various Microsoft programs
Fundamental understanding of HMO/PPO/POS delivery system and claims billing
Must be able to work flexible shifts

Employment type
Full-time

Work arrangement
Hybrid