Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Position Summary
The Provider Inquiry Resolution Specialist works with the PI supervisors, Claims, Benefits Administration Team, Network, Audit & Recovery, HMD and other internal departments the resolution of complex Provider issues. The Specialist shares feedback, trends, training opportunities, and provides suggestions for process improvements to the same groups. This role is the subject matter expert on claims processing, CMS Regulations, DHA regulations and medical billing within the PI department.
This is a hybrid role based out of Portland Maine.
Job Description
Key Outcomes:
- Reviews, researches and resolves the most complex claims related issues in partnership with our internal teams and the Provider.
- Works with appropriate internal departments as well as the Policy Benefit Administration Team to correct errors or provides direction for systemic changes through the IT department.
- Prevents providers from the needing to “escalate” calls or situations further.
- Tracks and trends issues to identify and address appropriately
- Partners with the Network team to resolve highly escalated issues with providers that may involve contracting or large exceptions to our standard claims procedures.
- Works with Supervisors and Trainer to develop reps through monitoring, coaching, and providing feedback to Provider Inquiry Representatives.
- Serves as primary contact for claims, network management and all other departments regarding escalated provider inquiries.
- Ensures that escalated provider inquiries are managed appropriately with key stakeholders for timely resolution.
- Represents the Provider Inquiry department on interdepartmental committees and work-groups.
- Assists in completing research, trending, and identifying opportunities to improve first call resolution, support improvements to training program and representative resources
Education/Experience
- High school diploma or equivalent.
- Experience in the area of Provider services in a healthcare setting.
- 2 years of experience in a MPHC Member Services and/or Provider Inquiry Representative related position.
Required License(s) and/or Certification(s):
Terms of employment may require the applicant/incumbent to qualify, obtain and maintain an ADP Privileged Position Level of Trustworthiness from the U.S. Government Office of Personnel Management.
Skills/Knowledge/Competencies (Behaviors):
- Outstanding customer service focus with the ability to relate to internal and external customers in a positive and professional manner.
- Communicates effectively and maintains positive relationships with all team-mates, management and other departments.
- Proven capacity to give and receive feedback in a constructive manner.
- Ability to communicate complex issues and workflows to a broad audience in a manner that supports understanding and learning.
- Knowledge of all aspects Provider Inquiry processes, Health Plan Operations, and understanding of interdepartmental dependencies.
- Capable of determining when issues need escalation of prioritization and have reliable follow through.
- Ability to maintain confidentiality of Member/healthcare information.
- Ability to work efficiently, independently and ability to work cooperatively with other departments.
- Strong computer skills (keyboard proficient, quick data entry with a high level of accuracy)
- Analytical skills in research and problem resolution
- Multi-task oriented with the ability to prioritize.
- Consistently meets or exceeds department expectations.
- Exhibits capacity to quickly learn new processes and workflows as required.
- Acts as a problem solver; discovers and helps resolve gaps in procedure and system support.
- Well organized, detail oriented with excellent follow up skills.
- Ability to handle crisis situations and easily adapt to change.
There are additional competencies linked to individual contributor, provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org