Senior Provider Service Representative

Optum is a global organization that delivers care, aided by technology, to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities.

About the role

This is a critical position within the Provider Services Department and a required position within our contract budget. The role is responsible for processing provider applications and contracts, completing provider credentialing and re-credentialing. The Senior Provider Services Representative manages provider networks that support the client base, including hospital, FFS, and TERM networks. Responsibilities include provider relation activities, analyzing provider performance, credentialing and recredentialing, and creating provider reimbursement arrangements.

The Contract Administrator may work with providers on the TERM and/or Medi-Cal Fee-For-Service (FFS) Network(s), as well as Off Panel, Out of Network providers, Skilled Nursing Facilities, Hospitals (including the San Diego County Psychiatric Hospital and Edgemoor Hospital), and other medical professionals.

Location: This role requires working 2 days onsite at 3131 Camino del Rio North, Suite 700, San Diego, CA, 92108. If you reside in San Diego, CA, you will enjoy the flexibility of a hybrid-remote role.

Responsibilities

• Manage the full range of provider relations and service interactions within UHG, focusing on end-to-end provider claims, call quality, and network support
• Manage provider interactions and ensure ease of the provider portal, including future service enhancements
• Support the development and delivery of external provider education and training programs
• Assist the Manager and Leadership in updating and developing provider data, workflows, systems, and other processes
• Support credentialing, recredentialing, enrollment, and contracting processes, including Letters of Agreement (LOAs), ensuring compliance with NCQA or County standards
• Order and support Primary Source Verification for Providers
• Oversee and maintain updated provider credentialing documentation, including DEA registration, clinical license, board certifications, and PLI
• Complete administrative processes related to applications and supporting documents to ensure compliance with credentialing criteria for inclusion in the FFS and TERM provider networks
• Collaborate with cross-functional teams to ensure seamless execution of site-wide processes
• Respond to provider requests (emails, calls, mail correspondence, and faxes) and inquiries, directing them to appropriate internal or external resources
• Design and implement programs to build and nurture positive relationships between the health plan, providers (physician, hospital, ancillary, etc.), and practice managers
• Contribute to the development and management of provider network strategies
• Identify gaps in provider network composition and services to assist the network contracting and development team in prioritizing contracting needs
• Identify and remediate operational shortfalls and research and remediate claims
• Follow up with providers to obtain necessary supporting documents and attestations required for contracting to maintain their network participation
• Ensure provider and group system setup forms are accurately completed and submitted to the appropriate internal departments for processing
• Plan, prioritize, and organize tasks to meet established goals and deadlines
• Design and deliver comprehensive, effective training that aligns with departmental goals and meets the needs of team members
• Develop report templates and generate reports to support provider data analysis
• Actively participate in meetings to support the achievement of departmental and cross-functional goals and objectives
• Perform and accurately enter and update provider data across multiple databases used for directories, payments, mailing, and reporting
• Maintain organized provider files for easy access by staff, leadership, and other departments
• Conduct peer review of providers' files to ensure accuracy and current supporting documents
• Document provider communication in designated systems and help maintain database integrity by verifying and updating provider information during interactions
• Provide support to Manager and Leadership in preparation for the annual audit
• Perform additional duties as assigned by Manager to successfully support the Department, Leadership, provider networks, and team

Requirements

• High School Diploma/GED
• 1+ years of data entry experience
• 1+ years of experience with provider contracting
• 1+ years of experience in the behavioral health managed care environment
• Intermediate level of proficiency with Microsoft Office applications

Skills

• Knowledge of EHR, SmartCare
• Excellent verbal, written, and interpersonal skills, including experience drafting correspondence and preparing meeting documentation
• Knowledge of reporting and data analysis
• Familiarity with SmartCare or other Electronic Health Record (EHR) systems, or similar platforms
• Ability to solve moderately complex problems independently and with the team
• Work is frequently completed without established procedures
• Ability to work independently and collaboratively in a fast-paced, multi-departmental environment
• Capable of acting as a resource for others
• Proactively identifies solutions to non-standard requests
• Applies knowledge/skills to a range of moderately complex activities
• High level of professionalism and integrity
• Exceptional organizational and time management skills
• Commitment to fostering diversity and inclusion across provider networks and organizational practices
• Strong focus on achieving measurable results and driving continuous improvement

Benefits

• Competitive base pay
• Paid Time Off (accrued from the first pay period) plus 8 paid holidays
• Medical plan options along with participation in a Health Spending Account or Health Savings Account
• Dental, Vision, Life & AD&D Insurance, along with Short-term and Long-Term Disability coverage
• 401(k) Savings Plan
• Employee Stock Purchase Plan
• Education Reimbursement
• Employee Discounts
• Employee Assistance Program
• Employee Referral Bonus Program
• Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)

Pay

The hourly pay for this role will range from $20.00 to $36.00 per hour based on full-time employment.

Schedule

Monday-Friday, 8:30am-5pm PST