Provider Service Representative III

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.

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.

Trips 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%)

Education 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.

Education Preferred

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.

Experience Preferred

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 Required

Licenses/Certifications Preferred

Licenses/Certifications Preferred

Required Training

Required Training

Preferred

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

Physical Requirements

Physical Requirements

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
• Retail Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)